THE FORGOTTEN

VOICES
EARLY GESTATIONAL LOSSES

Mónica Álvarez
M.angels Claramount
Laura g. Carrascosa
Cristina Silvente
 INTRODUCTION
If gestational losses are not treated, in general, as required by bereaved parents, those in the first half
of pregnancy are even less so, where misunderstanding and lack of validation and respect are
exacerbated.
The forgotten voices are those of these babies who lived alone in the womb, the voices of their
mothers who silenced their grief because they were too little, their babies were not big enough to be
mourned. And the voice of their parents who, even today, no one pays attention to them. The title also
refers to the social, medical and cultural oblivion into which these early losses fall.
In times of awareness: when so many couples must decide about the life of their babies because
medical advances detect so many fetal anomalies that were previously invisible; when medicine
speaks, and the head and the heart do not agree.
Early losses are real losses, bereaved families need to have their pain acknowledged: how small the
lost child is and how big a void it leaves.
It is important that, at the societal level, the mentality about abortion management changes. For years,
painkillers have been given at childbirth because women supposedly "didn't want to hear about it."
Nowadays, more and more of us want to know about our physiology in order to have conscious
deliveries. It should also be like this in the case of a loss: learn from the body, let it follow its rhythms,
its time to fulfill its mission. This is the true ritual, the most powerful one.
Does the image of a dead fetus disgust and frighten us? Or love and tenderness...? He is our son. We
talked about farewell rituals and their healing and transformative power for families, menstrual cycles
and their transformative potential. Repeated menstruation when seeking pregnancy means
experiencing a loss every month. The destructive nature of the comments of those around...
The beginning of pregnancy is the beginning of illusions, a project that is cut short when the emotion
of motherhood has just been felt; the shock of the positive news versus the shock of the negative news
in a short period of time. The loss of innocence and the theft forever of a happy pregnancy.
The phases of grief and the golden rules to go through it. The symbolic, the spiritual, the mystical. The
connection of life and death in the maternal womb. Subsequent pregnancies, repeat losses and fertility
problems.
Fear, that inseparable companion after loss that lurks forever from fertilization until after childbirth.
The anguish that this fear is bad for the life of the new baby on the way, brother of the one you are
suffering from.
The loneliness, isolation and misinformation experienced by the woman and her partner in the
experience of loss because there is no place to express or listen to a death that is not socially
contemplated.
The Forgotten Voices intends to deal in depth with a subject that humanity has been pending for
centuries: that oblivion gives way to a true interest; this is our objective and the work that moves us.

CHAPTER 1
It is special because of the time you put into it.
It is better to turn on a light than to curse the darkness (Arabic proverb).
When a couple decides that it is time to become parents and they start "looking" it is as if the being
that one day will be their child is already beginning to inhabit their lives. The couple is projecting into
the future.
The child begins to gestate on a mental and emotional level, even if it is imperceptible to those outside
the sphere of the couple. There are home tests that confirm pregnancy even before the due date with
surprising effectiveness. So the couple "knows" they are pregnant almost from the start. The euphoria
that can surround these moments can be incredible.
... the expectant mother has nausea, vomiting or any other symptom will feel unwell but pregnant, and
that will make her happy above any bodily discomfort she may have to endure. It is customary to tell
the family, to announce the good news, to let everyone know how happy and content you are with
your new status. Although it is too early to feel the little kicks or anything like that, the new mother
"feels" that this new being is inside her and she holds her hands to her belly in a protective gesture
towards this little embryo that is at that moment on its way to grow and take the shape of a human
baby. Happiness fills the home of the parents-to-be, who are amazed to see how such a small child can
already occupy such a large mental and emotional space in their lives.
A devastating experience strikes the couple's life. Something so painful and hard that it provokes a
deep and real existential crisis from which you don't get out the same way you came in.
The pieces can be reunited, but there will be gaps, grooves, that will leave a record of the work done
and of what is no longer there.
It seems that if there is something physical that "proves" that there was indeed a pregnancy, a being
beating in the mother's womb, it can be said that "nothing happened here".
We live under a paradigm in which Newton's mechanistic physics reigns: the person is a physical body
whose gears respond to a series of physical laws that can be anticipated, which does not give rise to
certain surprises. Inside the body there are a series of "tubes" of different types that allow liquids and
fluids to pass through the body, fulfilling their corresponding functions. Beyond the purely physical,
nothing exists. If it cannot be measured, counted, weighed, touched, seen, smelled... it does not exist.
If the little being that lived in her mother's womb is important for the time she dedicated to it while it
was beating inside her, for that time she spent thinking about it, imagining how her belly would grow,
the birth, the dreamed baby.
For part of society, it is nothing more than a bunch of dead cells that are not worth spending another
second on. On the other hand, for the mother, the father is special, he will always be in her heart, and
deserves to stop her life for a few moments to remember him, to cry for him, to feel how happy he was
while he was alive in her womb, to say goodbye to him and let him go.

Not measuring up
Imaginary baby/real baby
The problem for a mother who loses a baby at a few weeks gestation is not only that society does not
consider her as a mother and the baby as a child, but that she herself has difficulty imagining what is
popularly called "abortion" as a baby.
Talking about it and with other mothers and being accompanied in their process helps to address these
possible reactions and to be able to live without extreme anxiety the fact of having their dead baby in
the womb for a while; to be able, in the end, to talk about their desired and lost child.
It is very painful to imagine what it would be like if it never came to be, if it remained a project, a
disappointment and a scare.
To heal the pain it is necessary to go to the center, to the place where it hurts the most and let the tears
disinfect and heal the wound.
Many women cannot bear to see other babies when they have lost their own. But the problem is not in
those babies that a mother finds everywhere, but that the image she herself had of hers has not been
processed/healed and of which she will never have an image, a face, a smile.
A very important part of the postpartum period consists of adapting the real baby that the mother holds
in her arms to the one she had imagined during the 9 months of pregnancy.
It is a time of readjustment, of gradually finding the middle ground between the needs of mother and
baby.
But how will a woman who has not been able to hold her baby in her arms, who has not even seen it
because it did not even have a human form, carry out her puerperium? She imagines a "perfect baby".
But how will this image be checked against reality if permission to look at other babies is no longer
even granted? How will you make the transition from imaginary baby to real baby?
For a mother who loses her baby in late gestation, it can be terrible not to be allowed to see the baby.
Say goodbye to him as you would to any loved one. If you have a chance to see him, get to know his
face, take a picture of him, see who he looks like, you will have a good start to your mourning. At
least she would be left with the knowledge that her baby looked human, that she was just like the
others. But for a mother who loses her pregnancy in the first weeks, neither socially nor personally is
she allowed to imagine her child in human form because what she has expelled "was nothing more
than a fetus, something horrible, deformed that it is better not to see, a monster".
We know the therapeutic benefits of being able to see the child who died in childbirth in the
immediate vicinity, to see what it would look like, to give a real face to someone who for 9 months has
been an illusion. What happens when pregnancy stops in early stages has not been discussed. It is a
taboo, because, in addition to the fear of death, of seeing a dead being, there is also the latent fear of
seeing what we believe will be a "monster".
Why is it acceptable to see a photo of the living embryo but not to see the embryonic remains of what
is and will forever be your own child?
It may seem crazy to us, but not many years ago it was also crazy to expect to see the baby who dies in
the perinatal stage and now it is something that many people no longer question; on the contrary: those
of us who are dedicated to accompanying families in this trance see it as something normal and
necessary, that the mother may wish it and that it is also beneficial to say goodbye to the baby and to
manage the grief that she will have to deal with. Our minds are advancing geometrically and soon
seeing the mortal rest of the being that is your child will be the natural, logical thing to do, no matter
how big it is.
Poland is a country whose laws allow parents to bury the remains of their deceased children at any
time during gestation. They can be registered in the Civil Registry and in the Family Book. It also
makes it easier to have a community farewell ritual that recognizes you as a child in society. Maternity
leave is also available, which legitimizes the mother as a mother and allows her to take a few days to
rest and let her body recover from the hormonal imbalance of being pregnant and suddenly not being
pregnant, to organize her mental and emotional universe, to take time to establish a before and after in
her life.... This, in our country (Spain), is unthinkable, but also because our pace of life leads us to
forget that we have a body that needs some care and respect some times for its proper functioning. It
will be possible to bring about a change and achieve the necessary legal figures so that children who
die during pregnancy are socially accepted when we really value them, mourn them and recognize
within ourselves that we need time for our body, psyche and spirit to readjust muscularly, chemically
and hormonally.
The postpartum period without a baby
It is the total and sudden rupture with your own identity, with that which until the moment of giving
birth had defined you: your projects, your ambitions, your work, your friends, your body and
everything you called your own. Your time. Your life.
How do you live a puerperium when there is no baby? Some may read this and wonder what the
puerperium is. The puerperium is what used to be called "the quarantine": the forty days after
childbirth during which the woman did not leave the house and was cared for by other women while
she devoted herself exclusively to recovering and bonding with her baby.
It is a special period because during pregnancy there have been a series of hormonal changes that have
considerably altered the body. These changes were necessary for the normal evolution of the baby in
the womb, but after delivery, hormones must return to their pre-pregnancy levels.
This return to the origin does not occur quickly, but requires an intermediate period in which certain
hormones remain at different levels than they were before and during pregnancy. Why? The baby
needs to adapt to an environment that is very different from the mother's womb; it is very vulnerable
and needs maternal protection and care. The mother needs to know her baby, to learn to read his needs
in his gestures; to be one with him, to merge with him again.
Both need to recognize each other and meet again, in the fullest sense of the term. And to do so, both
must have their brains and bodies programmed and prepared for such an encounter, to pay no attention
to anything or almost anything else but themselves for the sole purpose of rebuilding that mother-baby
dyad that will guarantee their survival. A baby is life-changing in every way: the emotional state in
which the mother finds herself is a beautiful madness that takes over her life as if nothing else existed.
The mother should bond with the baby in a special way, and remain in this state of alertness, self-
absorption and absolute dedication for a while, at least long enough until the baby gains autonomy and
no longer needs such exclusive dedication.
All this is achieved thanks to a special hormonal state that will inevitably appear after childbirth. The
hormonal state of the puerperium creates a unique emotional state, ready to be impregnated with all
the details of the baby in order to achieve a unique bond. All the events that occur in the hours and
days and even months after delivery will be etched in the mother's mind in a special way. The
exacerbated maternal sensitivity will also make him especially vulnerable to any external stimulus that
disturbs him. Many are normal events that are part of the necessary mother-baby readjustment, and
since they can generate a certain sadness or distress, many people "misname" it as postpartum
depression, generalizing this state, as if all women suffer from depression in a physiological way after
childbirth. But postpartum depression and even the post-traumatic stress that occurs in many
postpartum women is something else: it is not physiological, but the consequence of suffering some
kind of traumatic event in this delicate period as a result of the puerperal hormonal balance. Hence,
when the mother has experienced a traumatic birth or her baby suffers some problem or simply as we
have mentioned, the image of her imaginary baby does not fit with the one she has in front of her, or
she encounters difficulties due to lack of support, help, empathy... all of them will affect the mother in
a unique way.
Within the hormonal constellation, another goal requires specific dedication and sensitivity: the
establishment and maintenance of lactation. This process also occurs as a consequence of a special
hormonal state that keeps prolactin levels elevated and unavoidably after childbirth, even if this
happens at a very early gestation period. This increase in prolactin will also reduce the mother's sexual
desire, prevent conception and ensure that the mother is fully devoted to her child.
For all these reasons, the puerperium is a special period that needs to be taken into account. Today it is
widely proven that the puerperium is not limited to those first forty days, but extends to the first years
of the baby's life, during which time the woman has to adapt to her new status as a mother, not only
socially, but also neurophysiologically and hormonally. It used to be said that "until the hormones
returned to their normal state", women lived in a kind of emotional roller coaster of joy, tears, various
emotions...
An old saying goes: "It takes a tribe to raise a child?
Many women who find themselves alone a few days after giving birth, with a crying baby who does
not respond to any manual, feel that they have gone crazy, with their universe turned upside down. Her
mental state is disrupted and she goes from being a woman with a schedule and an organization to
living immersed in a world of endless milk and diapers. Society does not validate these changes in
women, so the loneliness is double, because only another woman who has gone through it understands
what is happening to her. Currently, some psychologists are studying the needs of a new mother, and
the conclusion they reach is that many of them look to their own mothers for answers.
What does this have to do with gestational losses? Much because, together with the pain of loss, the
woman discovers to her astonishment that she has not only lost the child she was carrying in her womb
but that she is also going through this puerperal period in which she feels she is going crazy, and not
only with pain.
If the puerperium as a stage in the psychosexual and emotional cycle of women is generally devalued,
if there is no baby, it is not even taken into account.
The hormonal cocktail created during pregnancy brings out the most irrational instincts.
We should not worry because we do not want to hold or look at other babies: we just want to look at
our own baby, hold it, caress it, smell it, kiss it... The fact that there is no baby in the puerperium does
not mean that all these desires are not there, so that the deepest primary instinct arises and instinctively
drives away from other puppies of the human species. This is the way it should always be done: do not
interfere in the relationship between mother and baby with smells different from their own. Supporting
the expectant mother means supporting her, not the baby.
The postpartum period is a special time in a mother's life, whether she is holding her baby or not. She
is not crazy; she is a woman full of love for her baby. If a woman has a healthy baby after childbirth,
she may even appear unbalanced to those who do not understand how this period is experienced. What
does it look like to be the one who, in addition to the need to embrace her baby, has to mourn her loss?

Full breasts, empty arms.

Another significant aspect of the postpartum period that every mother goes through (even those who
decide to cut it short) is breastfeeding. This process is also a hormonal and physical revolution to
which she and the baby must get used to, and which the mother who suffers a gestational loss can also
go through.
Breast tissue undergoes changes from the first weeks of gestation due to increased levels of
progesterone, prolactin and placental lactogen. These hormones lead to a development of the
mammary glands, within which the lactiferous ducts blossom and expand, populating with branching
and secreting glands that resemble bunches of grapes, in a literal analogy to grapevines. During this
development, there will also be a series of genetic changes that will increase the expression of certain
proteins that will be, together with small fat droplets that also begin to accumulate there, part of the
essential ingredients of milk. This process is known as lactogenesis I.
At some point in this process, the development of the breast goes from "growth mode" to "secretory
mode", giving rise to a new phase within lactation, the formation of milk itself and secretion out of the
mammary gland: this is lactogenesis II.
Lactogenesis II involves not only the secretion of milk, but also the potential to do so. That is, milk
ejection occurs after delivery due to the abrupt decline of the same hormones that initiated
lactogenesis I and that were responsible for keeping "the stage set". It is at this point that the switch is
flipped that tells the mammary gland that it can switch to making milk and secrete it. But for this, the
stage has to be set in advance. So if labor occurs well before term we may find that the stage is set and
milk is produced despite the death of the baby.
Unless it is a late gestational loss, few people wonder about this aspect when a loss occurs. In fact, the
literature on gestational and perinatal losses, which sometimes covers some of the physical symptoms
after the loss, hardly discusses the impact of lactogenesis II on the mother and how the management of
lactogenesis II affects the mother in these cases. Only in the case of late gestational and perinatal
losses it is known that in premature deliveries, before 34 weeks, it is very frequent that lactogenesis II
does not occur immediately after delivery, but is delayed, especially if other circumstances concur,
such as the administration of corticosteroids during gestation to stimulate pulmonary maturation of the
baby.
What about early losses? Is it too soon? Or could we find cases of women experiencing milk surge?
Everything seems to indicate that yes, and these are not rare cases. The ability of the pregnant woman
to initiate lactogenesis II appears to take place around the second trimester of pregnancy. An increase
in blood lactose concentration has been found in pregnant women from 10-21 weeks gestational age,
which could be related to its potential to initiate lactogenesis II in case gestation was terminated at that
time.
The appearance of milk after a milk loss has important repercussions for the mother.
The big difference between lactogenesis in early and perinatal losses is that neither the mother nor the
professionals have taken it into account. The milk rises and, if it is the case, it is cut off
pharmacologically, once the rise has already occurred, which makes the medication lose much of its
effectiveness. Some mothers in early losses suddenly find themselves with this engorgement (many of
them after having undergone a curettage) that causes them a generally painful engorgement, without
being informed, without knowing where to turn, with the beginnings of mastitis even and without tools
to decongest or relieve the discomfort of an engorgement without the help of emptying the baby. If
they have not breastfed before, even without identifying what is happening to them, because they do
not believe that something like this can happen, especially if they are only a few weeks old.
It highlights the loneliness of mothers facing a taboo subject within the taboo of gestational loss. And
furthermore (unless they were in contact with breastfeeding support groups or knew of their existence
beforehand), at this time it does not even occur to them to turn to them. Lactation consultants can be of
great help in these difficult moments, as well as any professional knowledgeable in breastfeeding,
which today not all of them are. It would be advisable for all lactation consultants to be trained in
gestational bereavement support.
Given the possibility of this happening, all mothers who are experiencing a loss should be advised of
the possibility of milk let-down and the various ways to deal with it. Inform the woman of the
different possibilities of managing lactogenesis II in case of death of the baby in formation and let her
decide how she wants to proceed: by cutting off the milk pharmacologically or in a natural,
physiological way, as in a forced weaning; gradually, respecting the times.
This milk that "comes out on its own", as some mothers say, could be used for milk banks, for other
babies, or for the mother herself to facilitate her recovery, as other cultures use it for its healing
properties for adults.
So undervalued is this so-called "white gold" that is human milk for humans themselves...!
Unfortunately, a woman in this situation is not faced with this range of possibilities. Even a
practitioner aware of these options at an early loss will not provide the woman with transparent
information to enable her to choose one of them. Most often, the professionals decide for the mother
and offer her medication to stop the milk. Often without asking, without even asking for informed
consent.
In addition to the lack of options, few mothers receive reliable information based on scientific
evidence. For example, the use of pills to stop milk, although widespread and the "only option" for
many professionals, is strongly questioned. A recent review highlights the lack of studies
demonstrating the validity of many of the drugs routinely used to inhibit lactogenesis II. According to
this review, not only is its supremacy clearly demonstrated against non-pharmacological management
or non-treatment, but also the possible side effects are not adequately considered in scientific studies.
These effects have led, for example, to discourage its use in the inhibition of lactation.
But even non-pharmacological methods are not exempt from being submerged in unscientific criteria.
For example, compressive breast bandages have been shown to be ineffective in inhibiting milk let-
down; they increase pain and involuntary milk ejection, and the use of reinforced bras is more
appropriate. On the other hand, cabbage leaves or local cold treatment had a similar effect to the
placebo, although the massage associated with their application seems to contribute to alleviate
discomfort. Therefore, it is still recommended to insert cabbage leaves or a cold compress in the bra as
a complementary measure during the lactation inhibition process. With respect to acupuncture, it
appears to have a slight beneficial effect in reducing symptoms, but more studies are needed to
confirm its effectiveness.
Despite this, some of these methods have a power that goes beyond the physically quantifiable. Since
breastfeeding is not only a means of feeding the baby but also a form of emotional bonding with the
baby, it can play a crucial role during the elaboration of grief in this context. For example: in a study
conducted by Swedish nurses, breast bandaging was found to have a significant effect from an
emotional perspective. Beyond its inhibitory effects on lactation, for many women it served as a
physical element and a tool in itself to overcome grief over the loss of their baby. The mere act of
doing something physical that almost constituted a ritual was for them a step forward in coping with
the loss.
On the other hand, the engorgement that most lactation-inhibiting methods aim to combat is, per se, a
physiological mechanism that leads to the natural cessation of lactation. The accumulation of milk in
the lactiferous ducts stimulates the secretion of lactation-inhibiting protein (LIP) which, together with
reduced blood flow and involution of the milk-secreting gland, reduces milk production. The
effectiveness of engorgement in reducing milk production is however affected by the often occurrence
of pain and severe discomfort that also needs to be treated. Adequate support, informing the mother
about the importance of fair expression of the excess milk that generates these discomforts may be
sufficient to use the natural inhibitory physiology of lactogenesis without the side effects of other
methods. In these cases, the added use of anti-inflammatory drugs has also been shown to be effective
in helping to reduce the associated discomfort and makes this type of management an ideal option with
few side effects.
A recurring question for mothers going through a loss is: What is the appropriate time to wait before
seeking a new pregnancy? If the milk rises, the answer is given by nature, because the rise inhibits
ovulation for a while. In case of immediate and pharmacological milk withdrawal, if it is done in time
and with the right drug, the body resumes the cycles immediately. Perhaps this is one more reason to
consider resorting to the physiological management of lactogenesis II in case of gestational death.
Transient amenorrhea due to this cause helps to a faster recovery.
It is very tender to know what your baby looks like physically day by day from conception to birth.
Knowing exactly what it looks like helps to bond with it.
The problem is that when that little one dies, it is no longer something tiny that produces so much
tenderness. It becomes a kind of "horrifying monster" that one does not even want to see: a kind of
irrational fear arises to see face to face "that which has gestated in the most intimate part of the being.
We believe that this way of thinking of the fetus as a monster is very common and may come from the
Middle Ages. At that time, there was no way of knowing what was going on inside a mother's womb,
because even if a pregnant woman died, the Church forbade the dissection of corpses, which was
common in the Arab countries of that time, the cradle of medicine in those dark centuries. Popular
wisdom said that the man inserted the vital fluid into the woman (who was a mere recipient in the
whole process) and that, despite the small size, the new being that was formed already had in itself the
image it would have at birth, as the Bible proclaimed: "in the image and likeness of God". When
abortions took place, sometimes beings were born before their time with real malformations, which
were seen as aberrations, punishments from God for some sin committed by their parents or a close
relative, and they paid for their grave error in this way.
Perhaps this is the origin of the taboo and the need to hide abortions, because of what people would
say and the social punishment that could result, ostracism, death for the possible incestuous person.
This way of thinking, born directly from superstition and ignorance of modern science, has lasted until
today, and is the basis of the taboo that prevails around abortion.
Sin + punishment=abortion: so whoever suffers it better hide it so as not to suffer the social ostracism
to which the sinner was subjected.
The basis of this blaming thought pattern is still present in the way the mother is addressed. For
example: "maybe you didn't take good care of yourself", "you must have done something", "maybe
deep down you wanted it", "you didn't deserve it" and other cruelties that are said between women or
that are not said directly but are planned between the comadres, sometimes with a simple glance. Or
worse: there are still countries where it is illegal to voluntarily abort and doing so is punishable by
imprisonment.
What are we afraid of when it comes to seeing the remains of an embryo, what subconscious layer
moves us to provoke such rejection?
The lack of knowledge and the fallacy we have been sold that doctors are the ones who save our lives
lead many women to ask for a curettage as soon as possible: "Doctor, get that dead thing out of me
from in there!". This woman who speaks in this way about what until a few moments ago was her
beloved son, if she were properly informed and supported, would discover that "that dead thing" does
not pose any kind of danger to her body, just like many other dead substances that we carry around
with us every day at all hours, such as hair, nails, kilos of fecal matter that accumulate in our
intestines, the millions of dead skin cells and other types of cells that populate our entire body
internally and externally, which are continually being born and grow.The millions of dead skin and
other cells that populate our bodies internally and externally are continually being born, growing,
dying and undergoing the process necessary to be eliminated at the appropriate time. For some
women, knowing that they are carrying a dead embryo can even be traumatic because we are not used
to dealing with death in our society. Also, knowing that you have lost your baby and having to wait
weeks for your body to kick into gear and expel the remains can be a real test of patience because of
your desire for everything to pass and for you to be able to try again for a pregnancy, this time with a
happy ending.
It is not possible to grieve for someone with whom we are not emotionally involved.
Our society is, fundamentally, a denialist one. As a society we are blocked in this phase of mourning:
denial.
The physical need (without even mentioning the emotional or spiritual need, which are more
"ethereal") to take a break after an exhausting period such as pregnancy, especially one that ends in
loss, ends up being felt sooner or later and takes its toll. Thus, women are forced to return to work
because "working will be good for her". The result is not long in coming. From sick leave due to
depression because there is no mourning process; due to work stress because anxiety takes over the
truncated mother's life; because many women end up undergoing surgery unconsciously at the end of
what would have been the 9 months of gestation.
There is the mother who prefers to go to work as soon as possible so as not to spend hours at home
"thinking" and thinking about it. Perhaps this would be the right time to turn to a good therapist
specialized in perinatal grief who can direct and channel a grief work helping us to recover the lost
natural wisdom we need to go through it. Perhaps a psychologist, a doula, a virtual or face-to-face
group will replace in our modern life the tribe that once accompanied the mother on her personal
journey of grief. Perhaps, with the help of committed and prepared professionals, it is time to create
new tribes within our society to welcome, care for and guide desolate parents along the way.
When a couple has a child, they become a family, and this involves adjustments of each of the
members separately and of all of them to each other.
In the event that the baby is not born, the adjustments will be different, but they will also have to be
made. Many couples do not make it through this ordeal; these parents are subject to two strong forces
that threaten their stability: that of having achieved family status and that of having lost a child.
It is very important to take a real time to elaborate the mourning, to know in which phase you are, to
know that it will be normal to have certain feelings; that it will be within the expected to feel hot and
cold, pain and joy if a new baby arrives while you are still in the previous mourning; that even if the
cycles continue and there are more babies, and it is postponed, it will be necessary to do this work, and
that life always takes its toll sooner or later; it is necessary to live intensely, also the painful stages;
that the more intensely you can live, the greater the gifts that this stage will bring us. necessary to do
this work, and that life always takes its toll sooner or later; one must live intensely, also the painful
stages; that the more intensely one can live, the greater the gifts that this stage so hard and so difficult
to go through will bring us; that one must not be afraid to ask for help if necessary (at no time would it
be a failure; another myth inherited from our post-war grandparents: "you have to be strong and not
cry, asking for help is for failures, you have to bite the stone and leave your soul if necessary, but
without help") but a victory to our ego.

GOLDEN RULES: WHAT HELPS?

Much of the emotional recovery lies in taking good care of oneself, pampering oneself, taking into
consideration one's own needs above those of others, at a time of great vulnerability, and with
emotions and pain at the surface. Scientific studies on the behavior of our brain have long indicated
that emotional pain and physical pain reside in the same place in the brain.
To seek one's own well-being without regrets. Reward yourself every day with something: a bath, a
massage, a walk... It doesn't have to be something material, or sometimes it does. Although it is a huge
effort, it is worth it. Prepare or ask them to prepare food that they especially like, give the senses as a
gift: sight, smell, taste, hearing, touch; a book, music, a special drink...
It is important to be patient with yourself because grief is a process with its ups and downs. Accept the
good days and the bad days, the relapses. Give yourself time. Letting out whatever you feel without
resistance. If one day you are sad, accept that sadness and live it and express it according to your
needs. If we let emotions out, they have a chance to evaporate; if they are locked inside an attempt to
silence them, the opposite will happen.
Congratulate yourself for every achievement, big or small, for any progress, always congratulate
yourself; a self-pat on the back, a smile in the mirror. Every month or on each anniversary of the loss,
a woman may confine herself at home, relive the pain as on the first day, until the day comes when she
decides to go out, dressed in bright colors, and it is important that she congratulates herself for it. You
are well aware of the effort involved!
Crying relieves pain. Crying until you give up, crying for days and days, amazed at the amount of
tears that can be shed.
In her book Women Who Run with the Wolves, Clarissa Pinkola Estés talks about the healing power of
tears: "There are times in a woman's life when she cries incessantly, and even if she has the support
and help of her loved ones, she cannot stop crying (...) Tears serve to mend the tears of the psyche.
The situation is very serious, but the worst does not happen because tears give us a conscience. There
is no chance that we will fall asleep when we cry. And sleep is produced only for the body's rest (...)
Sometimes a woman: "I'm tired of crying..." But she has to keep doing it until her need is over. Some
women are amazed at the amount of water their bodies can produce when they cry. This does not last
forever, only until the soul finishes expressing itself in this wise way".
Shouting to release tension, aggression, anger, feelings that always surface after a loss, accompanied
by hitting pillows, cushions. Any expression that frees us and is safe for us and for others.
Getting close to nature, to open, oxygenated, light-filled places; the sea, the forest... walking on the
sand, touching the trees, the plants... All this helps to recover energy, to let go, to lift your spirits.
To relate to people with whom to express oneself freely, who understand and validate the loss. It can
be used for both verbalizing and writing. It is good to have a good receiver, but sometimes it is useful
even without one. Writing to draw outside of oneself as catharsis and because it helps to put words and
order to what one feels. Writing produces an inner alchemy: it helps to channel doubts, anger, guilt... It
heals wounds and helps to face fears.
It is a great support to share grief with people close to you, with your partner, family, friends; with
peers, people who have gone through the same thing and are in other stages of grief or similar. To be
able to talk about what happened, not to hide it or deny it, including young children. Everyone
experiences his or her own grief, and sharing prevents everyone from isolating himself or herself in his
or her grief. Supporting the other so that he/she can flow his/her state of mind, without taboos.
Seek specialized help if necessary: doctor, psychologist, psychiatrist, therapist, doula... of our
confidence. Professional help is not essential in all cases, but it is good to take into account this
possibility and evaluate it whenever you feel the need.
The time of introspection, of reflection, is necessary and of great help because the strength of the
recovery is within each one of us, and it is there where we will look for it with the recollection that all
mourning implies. Living through suffering is the best way to get out of it.
Go beyond the loss. If this is not achieved, we are only left with the face of loss; it helps to go further
and discover all that this baby that left so soon brings them, what gifts, what teachings... And most
importantly: that this creature of fast passage through their lives has made them mothers.
To go through mourning, to go through the path of pain to reach acceptance, to overcome, to live.
Avoiding this work can bring unpleasant surprises in the future, such as repressed emotion bursting
out at inopportune moments, exploding when least expected, in crises that originally came from other
reasons. These unresolved griefs may appear in the experience of other griefs or personal crises that
aggravate the present event. In the experience of grief there is a very important part of personal
growth, which is a value for life. And it is the only way to reach inner peace, to remember without
anguish or suffering the baby that did not reach aerial life.
It is helpful to protect yourself from people or situations that make the grieving mother feel bad and
rob her of energy, a resource she needs so badly before her weakened state of mind. The pain itself
wears out. It helps a lot to surround yourself with protection, with understanding, with that which
shelters and nurtures. It is not selfishness, it is a matter of survival.
The list is long and open-ended, no one person or experience is identical to another. Be guided by
what we feel and need at each stage of grief.
Nourish
The anxiety felt after the loss of a loved one can cause such opposite and extreme states as loss of
appetite or ravenous hunger. Proper nutrition and hydration is important after a gestational loss. If you
are not hungry, take a salad, for example, or something light and tasty; it is not advisable to go without
food or to replace the meal with a bun or a sweet. The body needs to recover, and for this the energy
provided by a healthy and nutritious meal is essential. The mind also needs nourishment: a depressed
mental state may be caused by a state of malnutrition maintained over time.
Neglecting nutrition (and proper hydration) would be another form of self-punishment.
The consequence is usually to lose or gain a considerable amount of weight in a short period of time.
This dietary imbalance and the weight variation it produces can lead to serious musculoskeletal and
hormonal problems. But the most important problem, which is often hidden, causing a feedback loop
of the dysfunctional eating pattern, is at the psychological level. A state of malnutrition provokes at
the biochemical level a feeling of tiredness that causes feelings of loneliness, sadness and hopelessness
to emerge. Cognitive dissonance and obsessive thoughts typical of depressive states appear.
Does it mean going into a depression? It could be yes or it could be a reflection of a state of
malnutrition. It would be necessary to prescribe a diet that ensures the recommended daily amounts of
the different nutrients as well as sufficient fluids and perhaps a nutritional supplement to help
compensate for the deficiencies already created. In cases of severe weight loss, even below the
recommended weight, it has been proven that only by regaining weight and eating properly can most
of the mental symptoms remit.
When we are sad, we don't usually feel like eating, much less cooking. It's time to let yourself be cared
for and let others do the cooking. The partner, the mother, the father... can take care of the feeding.
Sometimes you don't know what to say to a couple who have lost their baby; gifts are in abundance,
but an "I'm sorry" and a pot of broth or a casserole never hurt.

CHAPTER 2
Mourning: may the road continue with you

THE PHASES OF GRIEF

Grief is an initiatory path for the person who goes through it. You know when it starts (more or less)
but you don't know when it ends. It is usually a transit year, and during the second year we "review"
the facts and events of the previous year;
There are as many normal duels as there are people, as each one will add his or her personal
particularity that will make it unique and non-transferable. We will be talking about phases that may
alternate, may be simultaneous, may last for months or may be resolved so quickly that it may seem
that some of them have not even been experienced.
According to the Swiss psychiatrist Kubler-Ross, there are phases of grief: shock, denial, anger,
bargaining, sadness and acceptance.

Shock: this stage may last minutes or a few hours. This is the moment when the awareness of what is
happening falls on us like a bucket of cold water. The body remains blocked, still, mute. We are not
able to react either rationally or emotionally. It is at this stage that many couples are put at the cruel
crossroads of having to make a decision: Leave tomorrow? Terminate a pregnancy without giving time
to ask for a second opinion or even take a breath?
At this stage, no one should be pressured to make momentous decisions that will influence our lives
for the rest of our lives. How many times has a mother wondered why she did not ask for a second
opinion, or why she did not get informed so she could do something other than curettage, blaming
herself for having decided what she decided when in fact she could not do anything else. It is
important to know that this guilt is not real. In a state of shock one is not able to decide anything; the
neural connections that perform this function are blocked. We are only able to trust the person in front
of us and let ourselves be the vulnerable beings we are in those moments. The professionals who give
this type of bad news should be aware of the enormous responsibility they have, since the degree of
vulnerability in which a person in a state of shock finds themselves makes them, on most occasions,
delegate their decisions (the transcendental ones and those that are not) to the people they have in front
of them, doctors, in whom they fully trust that they will seek their greatest benefit and that of the baby
they carry inside them. These situations, given the extreme fragility of the nervous and neuronal
system, are breeding grounds for the creation of traumas if things are not done with due tact and care.
This phase can last minutes, hours or days, so a mother who receives the news today that her
pregnancy has stopped and tomorrow goes to the operating room to have a curettage (because she has
certainly not been given any other possibility and the professional has made the decision for her) will
surely still be in a state of shock. Your mind is in a trance-like state in which the conversations,
images and smells you perceive during the procedure may be recorded. This is why you should be
very careful how you treat them and, above all, what you talk about in their presence. In any case,
doing things in a hurry, in a situation where there really is none, the mother will end up having to
process two grievances: that of the baby that is not there and that of the decision she could not make
because she was left with not enough time.

Denial: the hormonal discharge generated by the state of shock causes a state of immense fatigue in
the body. As this phase subsides and cortisol levels return to normal, the mother (and father) begins to
awaken from a bad dream. In most cases, they are faced with an empty womb in which life no longer
nests. Without time to process all the information that came to them at this moment, it is as if certain
parts of the person do not quite believe that "there is no longer a baby there". We don't want to believe
what is happening. One has the feeling that reality is a dream and that the unreal is true. Some
common thoughts are: "it can't possibly be happening to me", "it can't be"... or even worse: we may
even deny that there was life in that womb until recently.
In this phase can remain all those people who tell us: "you will have another one", "you have to live"...
It is their way of not stirring their own past and their own beliefs. Who knows if these people did not
go through similar experiences and, instead of growing up, denied and denied their feelings of loss.
They have become "blind" who do not see the pain of others because one day they decided not to see
their own. But the worst thing is not what others tell you, but what you tell yourself. Sometimes, the
easiest thing to do is to run away from the pain, and denial is a defense mechanism that contributes
perfectly to this. Those who deny what has happened to them do not do so out of malice or ignorance,
but out of an inability to face the truth. It takes a lot of personal strength to take this path and continue.
There will be those who take more or less time to go through it; there will be those who decide to stay
for a while at some stage of the journey, while they gather strength and continue to the next one. What
is true is that, at this moment, the mother and father are unable to face the pain, so they will need
another stop on the way, necessary to reach the maturity that will lead them to be able to look pain in
the face.

Anger: We talk about healthy anger, the one that leads us to defend ourselves, to look for
responsibilities that do not correspond to us. And regain dignity. Only when this stage has been lived
will it be possible to move on to the next one. The problem is that sometimes we confuse the tree with
the forest and it is fine to seek answers to questions, but we must not forget that in this life there are
questions that have no answers, which cannot prevent us from continuing to walk towards the next
goal. One can get into a legal process that lasts for years, encouraged in principle by this need to fight,
which is typical of this phase. The process can be delayed, and we can move on to the next phases and
live it more rationally, being cold in our responses and sometimes, thanks to that coldness, more
accurate.
At this stage, the person will be on edge and discussion will arise at many times. Keep in mind (the
partner and other family members) that these discrepancies should not be taken personally, but are a
way for the mother or father to release the anger and pain that is beginning to stir in the psyche. This
stage is usually very easy to see in men, but not so much in women who, because of their culture,
many have not learned to express their anger and rage. It would be necessary to be attentive that this
rage does not go inward and become violent acts against herself through food, alcohol... Externally,
the woman appears to be fine, but internally a sea of emotions swirls that can jump at the least
expected moment.
Although this taboo is beginning to be overcome, the truth is that we have a lot of difficulty expressing
our anger after generations of indoctrination in which we have been told that "we have to be good
girls". As Klarissa Pinkola Estés says, "we are domestic wolves, but underneath the skirt and the lace,
a beautiful Wild Woman's tail peeks out."
There is another characteristic of anger at this stage that occurs in almost all deaths of loved ones and
is a source of deep guilt: it is being angry at the dead person. A mother can get angry with her son for
leaving her, for not staying and making that beautiful life project they had a reality. Those who stay
are left disconsolate and with a thousand unanswered questions. Anger against the person who is gone,
in this case against the baby, is perfectly healthy. Getting it out and verbalizing it will do the child no
harm, and for parents it will be a sure passport to mental and emotional health.
Other emotional modalities can also occur, such as ambivalence, which is "wanting and not wanting
something", two opposite emotions that are experienced at the same time; it seems the height of
madness, but it happens ineluctably: that neighbor who approaches you and asks you about your loss
and how you are and it annoys you enormously because that person can have so little tact to ask you,
knowing what you are going through... Another neighbor who approaches you and does not say
anything and you think "how can this woman have so little tact and not ask me how I am, if she knows
what I am going through...". It may be that a woman who at the same time is grieving for her little one,
is pregnant with another one, and feels joy and sorrow... And she feels guilty for feeling joy for the
one who is coming, not being the other one; and she feels guilty for not feeling more love for the one
who is coming, for not giving herself permission to bond with him, lest he will leave too.
Love goes hand in hand with madness and it is possible for all these feelings to manifest themselves
simultaneously.
At this stage of the duel, the dangerous thing would be to feel nothing.
It may happen that the mourning of the lost child is joined by the mourning for those people who have
not been able to connect with the mourners, immersed in their own inability to live the pain and in
denial of it. Situations can arise that arouse anger because of the lack of understanding, because of the
well-intentioned words that hurt the deepest, because of the emptiness and the silence that is produced
as if nothing had happened. It is often recommended not to associate with people who do not
contribute anything positive, which can be difficult when it is one's own family. The moment of the
anger phase is not the most appropriate time to ask for accountability, nor to "try to make them see
reason". It may be interesting to avoid these family meetings and avoid getting into didactic fights that
lead nowhere, since everyone is right in their own way. Letting time pass, not to deny as they do, but
to be in another perspective oneself is often interesting. Over time, grieving parents learn not to let
themselves be hurt, although there are wounds of the soul that last forever. Sometimes, in addition to a
child, a parent is lost.
In short, we are talking about a time in which, especially in women, anger remains inward, often
overlapped by sadness (more socially accepted, although not too much). But just because we don't go
around hurling punches and swearing, doesn't mean that all that violence isn't there. We eat it. We
direct it to us. It is a stage marked by self-punishment (to a greater or lesser degree) brought about by
guilt (irrational belief). Until one moves from guilt to responsibility for oneself, one will not ascend to
the following stages: healthy anger, serene sadness, acceptance....

Denial: we start to believe what is happening and a negotiation against the clock begins with God,
with the Universe, with... If I stop smoking, if I rest, if I behave myself... will I recover? Sometimes it
works, and they tell us that all is not lost, that with a lot of rest or this medicine or whatever, we will
recover and have the baby. Most of the time, Life is not in our hands. In this story there is a third party
(the being of light that your baby is) who also chooses whether to leave or stay.
This negotiation can occur at a time prior to the loss or after the loss if another pregnancy is sought, or
if one is already pregnant... Dr. Kubler-Ross applied this phase to the time when the person who has
been diagnosed with a serious illness tries to negotiate a possible cure; a negotiation in which one
would "lose" something in exchange for gaining something else. He discovered that a large number of
his patients made this negotiation with God, that someone they each believed in even though prior to
the illness many had considered themselves atheists or agnostics. It also turned out that many of the
believers were angry with that god who allowed "this" to happen. In any case, he found that the
resolution of this phase was more accurate if the sick person was able to accept that there was a being
above him with the power to do and undo; that is, if he was able to awaken the spiritual part dormant
within him, possibly for many years. In our daily contact with grieving mothers, we observe that if
there is a religious belief, the grief is much easier to bear, although it is no less painful. Spirituality is
not a cover under which to keep the pain or an anesthetic, but rather a way of facing life and all that it
brings: the good and the bad.

Sadness: just as in a banquet, the other dishes are a kind of preparation for the main course. The first
few days after the loss, our psyche is not prepared to cope with all the pain we will feel. It needs a kind
of preparation, a long-distance race until we reach the point of maturity where we can finally accept
the pain of those who have not passed. Serene sadness. When one has expelled all the anger and can
finally cry, cry for the one who has gone and will be no more; cry for that part of oneself that we also
irremediably lose; cry for the situation that dies to give way to another perhaps not so pleasant; cry for
oneself, for the pain that tears.... Crying calms, and salty tears disinfect and help to heal the wound;
cry for the pain of our fellow men, who are more like us than ever. Crying for pain with capital letters.
In this phase we women have a small advantage over men, and that is that socially it is better seen the
cry of a woman (although not always) than that of a man. Men will also have to summon up the
courage to go through this phase without misrepresenting themselves, entering the open tomb through
the great door of pain.
It is known that the phases of grief will not be experienced by both partners at the same time. The
woman is in the throes of grief when she learns that she was carrying a child in her womb and that she
is no longer there. Sometimes a man is not aware that he is going to be a father until he sees his wife's
belly swell. He does not experience the discomfort of pregnancy from day one, so an early loss may
catch him not fully coming to terms with his parenthood. In any case, at first the father will be more
concerned about the life of his wife than that of the baby. It is more practical in that sense. And
someone is going to have to take care of the mother, who is also physically going through the process.
Therefore, the bereavement and its phases will be experienced differently by the father and the mother.
And if we add to this the difficulty that some men may have in entering this phase of pain, we already
have a formulated problem. When the man reaches this stage, perhaps the woman has already assumed
her own mourning, has completed her work and is in a position to be the one to take care of the man,
as a way of closing the circle.

Acceptance: when we have cried and healed, acceptance comes. This means having learned to let go
every day of the backpack that we unwittingly carry with us, a backpack that carries the weight of
those who are not here and those who, being here, do not mourn those who are not here. It is a weight
that prevents us from moving forward. We cannot weep for what belongs to others. Everyone must
carry their own backpack and drop it at the right time.
Letting go, loosening up, healing, walking without weight, with our heads held high and the sun and
the breeze caressing our cheeks...
We have explained grief as if it were exclusively a psychological event, but it is not. Many people who
knew the "theory", when they had to live the loss in their own flesh discovered that not only their soul
hurt, but also their body, in which multiple symptoms appeared. It is true that when the person does
not speak, the body speaks, and many times somatizations of an unresolved grief can appear even
many years later. Others are common manifestations. The problem tends to be that although almost
nobody consults a psychologist to help them through their grief, they do go to their family doctor
when they begin to have certain physical symptoms.If the doctor does not take into account that it may
be a manifestation of the grieving process itself, he or she will medicate and load them with useless
pills that will only mask some symptoms that, later on, will provoke others.
According to the Orientals, we have a physical body, a mental body, an emotional body, an energetic
body and other subtle bodies. All of them interact, and when there are movements in one (or
blockages), their manifestation may appear in another.
In his book "The Way of Tears", Jorge Bucay talks about "the mourning of the body" and notes the
following list of symptoms: nauseas, palpitaciones, pérdida de apetito, insomnio, fatiga, sensación de
falta de aire, punzadas en el pecho, pérdida de fuerza, dolor de espalda, temblores, hipersensibilidad al
ruido, dificultad para tragar, oleadas de calor, visióblurred vision, crying, sighing, looking for and
calling a loved one who is not there, wanting to be alone, avoiding people, sleeping too little or too
much, distractions, forgetfulness, lack of concentration, dreaming or having nightmares, lack of
interest in sex, not stopping to do things or apathy.
All of these symptoms are normal in a normal bereavement, and it is also possible that they may be
reactivated on anniversaries, perhaps even for years. When much time passes and we may even forget
that "so many years ago today it happened..." a headache or a tightness in the throat will remind us of
it. Because if we don't speak, the body will do it for us.

Enter spiral
It can take years to come to a total acceptance of what has happened (we are talking about intense
emotional losses). The beginning is experienced as if in slow motion. The first weeks are days full of
anniversaries: the first week after "your" loss; if this happened on a Thursday, for example, all
Thursdays will be especially intense, although the first days, they all are. The first hour or the first
fifteen days are still tinged perhaps with physical wounds that keep present and real what has
happened. The third week arrives against all odds (one never ceases to be amazed at every moment
that the entire planet continues to spin and that each person who inhabits it continues with his or her
life as if nothing had happened) and the date of the first month surprises with the certainty that even if
one does not want to, time passes marking a terribly painful distance with the loved one who is no
longer there. The day of the week and the day of the month in which it occurred are dates that are
engraved in the personal calendar of the mother who no longer has a baby in the womb to take care of
(and be cared for) and expect to feel it grow. Perhaps there was already an agenda of days marked with
medical visits, the "echo" of the twelfth week, the twentieth week.... These are key days on the
calendar that, without realizing it, come and go, irremediably marking a physical distance from the day
on which the world stopped, diluting a pain that one does not want to give up, as if deepening the
wound so that it continues to hurt would make a pregnancy and a being that few people remember as
someone who existed in the world more real. When the probable date of delivery approaches, a
curious phenomenon may occur: the parents may need to give birth to themselves as new persons, in
an attempt to give vent to the energetic need to give birth that the mother may feel, as if she were
preparing for a real birth, for another culminating moment in her life. These are sad days, but they can
be filled with meaning if you know how to take advantage of them to carry out the corresponding
therapeutic work. Perhaps it is time for another ritual and to say goodbye again to the baby that will
not fill her arms. There is usually then a small truce until the date when the mother became pregnant
again, the experiences she had, the moments of happiness, the terrible news... and then it starts all over
again.
However, many people say that the second year "is easier". This may be because they relive moments
that they have already lived through, but with the baggage that comes from the experience already
lived. Thus, the first anniversary can be very hard, but it is lived from the distance of the elapsed time.
Some of the phases can be reactivated but from a different perspective: that of experience and learning
from what has been experienced and having integrated everything a little more. The same will happen
in the following years. Time does not cure everything, but it gives enough perspective to see
everything from a distance. Suddenly one day you start to cry, you take out your box of memories and
burst into tears for what could have been and was not. And maybe in that first year you didn't give
yourself permission to cry because you had enough to survive and simply inhale air, one breath after
another. You discover that the passage of time has been necessary to discover what comforts crying.
We would speak of grief as a spiral that grows upwards in time, as a path that we travel through which
we go back over the starting point, of the different moments that were important a year ago, two years
ago or whatever, but that are lived from the distance that marks time and being another person.
This happens, at least, most of the year, because it is also true that the days close to the anniversary
dates are very hard, as psychoemotional and physical mechanisms that one thought had been
overcome are set in motion again. But it is part of the lot, it is expected that after a year, two or more
the person will have overcome their pain.
These anniversaries are often lived in solitude, since the rest of the family has long since moved on.
They are painful in themselves, and even more so because they revive the feelings of loneliness and
isolation that surrounded the loss of the baby due to the lack of social and family support that many
parents suffer.
It is a road that must necessarily be traveled. Some studies show that the medication sometimes given
to attenuate symptoms only postpones what must inevitably be experienced. Not only that, but it
prevents the brain from creating the necessary connections to be able to grieve and grow through it.
It is interesting to count on the hand of someone who accompanies us along the way, guiding us,
reminding us that at the end of the tunnel we will see the light again.
A professional will not make the grief go away, but it will help us to go through it in a more conscious
way. Therapeutic groups, either face-to-face or online, are also a great emotional support for these
parents. Seeing how others have already traveled the road ahead and seeing that they "did not die in
the attempt" is a point of hope.
A loss is always a test that life gives us to learn something. It is not the most pleasant way to learn, I
wish it could be acquired in another way, but since there is no other choice, it is interesting to make
the most of it.
Our society does not help us to grieve properly. Introspection is frowned upon.
The previous generation lived the gestational losses from denial (nothing happened here, let's pretend
nothing happened, we will suffer less). Those of us who want to live our losses from the point of view
of conscience clash terribly with our mothers, friends, with a large part of society that has remained
anchored in this phase of grief. For those who want to know, to see, to be informed, to touch, to
smell... the messages of those who should be a support on their path of personal discovery, on their
initiatory path, can be terribly offensive. But how are they going to accompany us in our transit, in our
therapeutic path if they have not done it before and do not even know what it is?
Grief is a path of learning, of initiation, an opportunity that life gives us to wake up and recover our
nature, our wildness, our strength.
The last phase of the duel will be "Restarting the wheel whenever necessary".

Particularities of gestational mourning compared to other types of mourning

The pain that is silenced is more painful (Jean Racine)
Is gestational bereavement different from other types of bereavement? The answer is "no"; they all
share the same path and feelings. And although all bereavements have points in common, there are no
identical people or exact experiences. There are similarities that allow us to establish generalities
where we all identify ourselves.
Having said that, we can talk about some particularities of this type of duels.
We speak of mourning for the death of an imagined, idealized, hoped-for person, whom we have not
been able to know as an individual being, independent of another being. Whom we have not been able
to identify in a face, a voice. The loss of an unreleased motherhood and fatherhood. The mother has
shared a part of her life with the baby emotionally and physically, which differentiates her from the
father, who has not had this connection.
This mourning is particular because in many mothers and fathers there is the need to be able to offer
unconditional love to a little one, to love him, to see him grow... this feeling is different in the case of
other close deaths.
Another difference is the passage through an "unauthorized" mourning that manifests itself in losses at
the beginning of pregnancy, when there have not yet been any external physical changes that are not
evident but are internal and noticeable. The pregnant body begins the transformation from the very
first moments, and the beginning is very intense: a whole revolution, a hormonal torrent that is set in
motion with force to support, shelter and nourish this new life. The mother perceives these changes
consciously or unconsciously.
But when this new life stops, culturally it is denied that anything substantial has happened. This
disjunctive makes the mother feel crazy; to feel what she feels and to live it without social
authorization unhinges the mother, the part. With a "tribal" recognition, close and true, the mother
would be provided with a validating accompaniment of the necessary expression of this grief. It is a
facilitating ritual. Western culture inhibits the mother from this expression that sometimes is retained
for years inside her and comes to the surface in especially hard and validated vital moments, because it
is a pending task of the psyche that takes advantage of any powerful "excuse" to manifest itself.
Silencing can lead to complicated grief or trigger pathological grief.
In addition to increasing the feeling of guilt for not living up to what is expected of this woman, not
only has she not been able to carry a pregnancy and culminate it with a baby in her arms, but she is not
even able to cope with this experience.
And there remains another extremely important pending task: to bring a living child into the world
who will stay. This is the urgency felt by the vast majority of mothers to get well right away and get
down to the task of fathering again. But they are grieving and this fact especially affects sexual
relations.
If the parents are older, they may have the feeling of losing their last chance. Here we encounter yet
another difference with respect to the other mourning: the mourning of fertility in addition to the
mourning of the loss itself. We can say that a gestational mourning is generally accompanied by other
intrinsic mourning.
A woman does not always experience this urge to become pregnant after a loss, as she feels the need
to recover and regain the emotional and physical strength to face a new pregnancy. Still, he has this
pending task, the space he had created for this new being has been left empty and calls to be filled
with a sibling of the departed one.
And there is one more urgency that is imposed on the mother by the lack of social validation and that
differentiates these mourning from the others: to impose on her to recover now.
The reproductive history of each woman, together with the context of the loss, will also mark the
difference from one experience to another and the degree of bonding established with the new being
on the way rather than the gestational age of the loss.

Duels in addition to the duel

We will find other causes that could also be the object of mourning in addition to the loss.

Ectopic Pregnancy and Fallopian Tube Leakage

The fertilized egg travels through the fallopian tube to the uterine cavity, where it seeks to implant. In
1 in 40 to 100 pregnancies, the zygote, instead of traveling to the uterus and implanting there, will
remain in the fallopian tube of the ovary of the recipient or more rarely in the ovary, stomach or
cervix. These pregnancies cannot progress, since the place where the fertilized egg is placed does not
have the appropriate characteristics for this purpose. The most numerous are those that occur in some
of the tubes.
It is unusual for the mother to notice that something unusual is going on. You may notice some pain or
discomfort in the corresponding ovarian area. The problem comes when the embryo grows and the
tube bursts, producing intense pain, internal bleeding... Immediate hospitalization of the mother and
surgical intervention is necessary to stop the bleeding and pain. They also collect the remains of the
embryo; this is a clear case in which curettage is not necessary (because the remains are in the tube
and not in the uterus). Sometimes surgery is performed before the tube bursts and it can be
reconstructed, although the problem is that it may recur in future pregnancies.
The pain of knowing that a child has been lost is compounded by the complication of having lost a
fallopian tube and, in addition, knowing that one's own life has been endangered.
In principle, there should be no problem in achieving another pregnancy, since the other tube and your
ovary are functioning. The uncertainty is whether the ectopic pregnancy could be repeated with the
added danger that if the other tube fails, the possibility of achieving a natural pregnancy would end,
thus lurking the shadow of sterility.
Ectopic pregnancy usually occurs due to a condition that obstructs or delays the passage of the zygote,
so that it ends up implanting in the fallopian tube. This condition can be caused by congenital tubal
defects, complications of appendicitis, endometriosis or scarring caused by previous pelvic surgery,
among other reasons.
Becoming aware of having a "defective" reproductive system is a hard shock for women. Therefore, it
is important to work on the owner for a body that was believed to be "perfect" and that does not work
as it should, endangering not only the children conceived, but also the mother herself.

When was the last attempt

Sometimes a family does not consider having more children because of age, because the previous
children are older, because they have already experienced several losses and have decided that this is
the last attempt... The mother becomes pregnant, whether she wanted to or not, and the pregnancy and
the new life are lived with great illusion, as if she had won the lottery and suddenly the sun shone in a
dark morning. But that pregnancy fails, and desolation comes with the certainty that there will be no
more chances to try.
It will be different if there were already more children. But if there are none, it will certainly be a very
deep duel. It may be a couple that has met late, close to their forties, or that the call of motherhood has
come to them at this time.
It is true that if there are no specific fertility problems, this duel could be turned around through
assisted reproduction. Nowadays women can have children until very late in our reproductive life.
There have been cases of women who have skipped even the psychological barrier of 50 and have
conceived and given birth without problems.
But there are certainly specific cases in which this is not possible; in these cases it will be more
important than ever to manage this grief and take it into account.

When the reproductive system is damaged

There is evidence of cases, very few, in which the uterus has been perforated after curettage, or the
endometrial wall has been scarred, or the ovaries and/or fallopian tubes have been damaged. As a
result, the woman has to face three duels:
- The loss of the baby I was expecting.
- The end of their reproductive life.
- The loss of health by having a damaged or diseased organ.
Whether you had more children or not, the end of reproductive life is a hard blow when what you want
most is another baby. It could be that it is the man who has seen his reproductive life come to an end.
The woman can still benefit from donor assisted reproduction techniques. Or they may choose the
adoption route directly. In any case, it will be necessary to mourn for children of their own blood that
they will no longer be able to have.

When is the last blastocyst

Not even the most advanced science can ensure that the members of a couple can become parents at
any cost. There will come a time when the financial and emotional cost of treatment will lead to a
decision to "enough is enough". It is true that in many cases success crowns these treatments, but in
those cases in which it is not possible, after many attempts and consecutive losses, in addition to the
months of hormonal treatment with the emotional complication that this entails for the mother,
sometimes the decision to terminate is the right one and it will also be necessary to work through a
mourning process. Perhaps not that of motherhood, because some couples exhaust this route, deciding
to continue with adoption, but the mourning for having their own child, from their own womb.
Sometimes it is the frozen embryos from your own egg and your partner's sperm, or from a sperm
donor, that are used up. Sometimes it is the last one and is lost, and the mother decides to gestate an
adopted embryo, donated by an anonymous couple. We may get lost in subtleties of form, but the duel
will be there accompanying us on our journey. Sometimes a sweet path leads to a good solution; other
times, not so much, if the renunciation of motherhood has to be total. But sooner or later it will be
necessary to look it in the face and go through it. For our sake and for the sake of our children.

Induced abortion in youth and unwanted abortion in adulthood

The experience of mothers who have planned an abortion, this is usually the time to mourn for the
baby that has just gone, for the one that left years ago, for the reality that takes away our certainties as
adult women, and to give way to the new woman who is about to come.
A woman's reproductive age is sometimes divided into two phases: the years spent trying not to get
pregnant and the years spent trying to get pregnant. Both phases are usually hard, but especially the
second one, because there can be so many circumstances that make the desired motherhood is delayed
or does not come, that you come to appreciate the importance of the miracle of life as something that
happens when "it" wants and not when we pawn others. The woman who survives this initiatory
journey becomes a wise woman.

The lost twin

Sometimes in a twin pregnancy one of the babies dies. Faced with this loss, parents will need to work
through their grief. It will be especially complicated because the joy of receiving the baby alive will be
accompanied by the sadness of having lost a child as well. The survivor, even if he fills his parents and
relatives with joy, will be all his life the permanent memory of the brother who died.
In many of these losses, parents who are told on the first ultrasound that two nested gestational sacs
are visible, are dismayed to discover on the second ultrasound that one of their twins is "missing".
What happened? It seems to be very common: one of the babies does not progress and is reabsorbed
by the mother's body or by the placenta. This phenomenon is known as "evanescent twin" or "phantom
twin. Exceptionally, it could fuse with the sibling's own body. He would be integrated into it in such a
way that his body would actually be a mixture of the two; he would then possess two different types of
cells, each with a different genetic constitution, as if they were two persons in one.
Other times, what happens is that the twin is integrated into the sibling's body but as a separate entity,
in the form of a grouping of embryonic cells and tissues (teratoma) located in a specific place and
whose growth can cause damage or even compromise the survival of the twin that harbors it
depending on where it is located and how much it develops inside.
When the loss occurs after the first 8-10 weeks, the baby does not disappear, but remains in the
mother's uterus with the size it had when it died while it undergoes a gradual process of "compression"
of its tissues by the loss of fluid from its body, which gives it a mummified appearance.
Early spontaneous twin loss is relatively common, as there are many cases of twins who do not survive
the first trimester of gestation.
It is estimated that one in 80 pregnancies are multiples at onset, but that only 6 out of 10 thrive as
twins. This fact is opening up a whole field of research on the possible psychological sequelae derived
from these losses in the surviving twin. There are many cases of these "only" twins who learned as
adults of the existence of another sibling with whom they shared a womb, their first home, even if only
for a short period of time, and the account of certain characteristics of their psyche show similarities.
On the other hand, the loss itself seems to affect the way in which parents treat and relate to the
surviving child, as their gestation is often accompanied by numerous fears about the risk of losing the
child in the same way as their sibling and because these babies are more at risk of developmental
problems.
Although it is not a new phenomenon, the increase in assisted reproduction techniques has increased
the incidence of this type of losses. On the one hand, they are contributing to an increase in the
number of multiple pregnancies, and on the other hand, since they are more closely monitored from
the beginning and the number of implanted embryos is known with certainty, there are more cases of
women who are aware of the loss of their baby that in other circumstances might otherwise go
unnoticed.
This is generating more and more situations in which these losses involve a mourning that, before the
existence and rise of these techniques, did not take place.
The problem with the loss of a twin is that it is another minimized grief, because the denial that arises
from the loss will cause the typical phrase: but if you have another one, why are you sad?
It is a complicated mourning because in it coexist the sorrow for the son who died and the joy for the
one who remains. The parents themselves have the feeling that they have no right to be sad because
they already have a prize: the surviving twin. It is very likely that guilt will arise because of the loyalty
they may feel towards the one who died, as if they forget him because they are happy for the one who
lives. Likewise, they may feel guilty for being sad, for not giving a happy reception and upbringing to
the living baby. And, at the same time, they may be feeling overwhelmed by the magnitude of the
emotions linked to this ambivalent situation they are experiencing.
From the moment the parents learn of the news that they are carrying two little ones, their life will be
planned around the existence of both children. If one dies, not only do they lose one of the babies, but
the loss of the "couple" that formed both children joins the mourning. Twins have an identity of their
own that is different from babies that are gestated individually. The clothes, the stroller... everything is
adapted for a couple of babies. In the parents' minds, the couple is already formed, even if they only
measure a few centimeters in the uterus. If one dies, so does the illusion, the expectations, the life they
had imagined raising a couple of babies at the same time.
In some cases, the existence of a twin is known a posteriori: after birth or much later, in adulthood,
when, for example, a cyst is removed and analyzed. And there is a duel. Sometimes, it is the
confirmation of information felt in some way by the sibling who was born alive.
It will be interesting to check the mourning of the twin who is born, because his life will surely be
marked by the story of a sibling he did not get to know. It will be a mourning to be lived in small
stages throughout life, because there will always be the feeling that you are missing "your other half"
just to walk the path. It is important for the child to know that he/she had a twin, to say goodbye to
him/her and even to create some ritual that links them.
It is a duel to be worked on just like the others. Having a healthy child does not make the loss of the
one who dies any less painful.
It is very important for each person to know his or her true identity, to know who he or she is and
where he or she comes from.

Selective fetal reduction

Another grief in cases of twins is that which occurs during assisted reproduction treatments.
Sometimes several embryos are implanted in the mother's uterus so that there is a greater chance that
one of them will last. It usually happens that only one or two reach the end of their gestation. But it
can also happen that most of them manage to establish themselves and move forward. On these
occasions, the parents are offered the option of making a selection of embryos, causing the death of
some of them to avoid multiple pregnancies. For professionals involved in assisted reproduction, this
is so commonplace that many do not give it the importance it deserves, but special attention should be
paid to these parents who are so emotionally overloaded at that moment that perhaps they
unconsciously postpone the mourning for another time in the future when they can process it. What
goes through the minds of parents who have to make such a decision? What must it be like to grieve
for children whose embryos are already implanted and growing on their path of transformation inside
the uterus? And especially when this achievement has cost so much, in many cases. It doesn't matter
how many are lost; one is already a road of mourning to travel. When they grow up, it will be
necessary to explain to the surviving siblings that they lived with other siblings in their first home.
Parents will have to take time to coexist with the joy and sadness of the experience they are going
through. It is very important to know all this, because the grief may come at another vital moment
when apparently "nothing has happened" to justify it. It is necessary to know that an unlived grief is
like a pending account that will be taken up again in the future when one is ready to face it.

Mourning for the one I was and never to be again

This grief may be very obvious, but it should not be so obvious when those of us who work with
women who have lost their child in the womb hear them complaining about the requests of family and
friends:
- Let's see if you get over it and go back to your old self.
- It's been a while and you need to get back to your life.
- It's time for the woman we knew to come back.
- Maybe if you stop thinking about the baby all day long you will get over it and go back to
your old self.
But the truth is that "the usual" will not return, because after such an experience, the one that one was
also dies, and with it the life as it was known.
Asking someone to go back to her old self is an attempt on the part of the rest of us not to grow, not to
evolve from a fact that, no matter how much we want to deny it, is real.
Because, it is not that "the one that was" has gone anywhere, but that "the one that is" has changed, has
expanded, is different because it has grown. This way of coping with life and difficulties is called
"resilience".

Psychologization of loss
People look for the cause of the loss, we need to understand why it happened.
And in this process of questions and answers, psychological causes also appear.
At present, it is impossible to establish a direct cause-effect relationship. It is clear that psychological
factors affect health, but from there to claiming that an unconscious desire has caused the pregnancy
not to take its course goes a long way.
In the grieving process it is normal for guilt to surface. They are attempts of the mind to find an
answer. Mothers already feel guilty.
The problem with guilt is that the person is left with guilt and no tools to deal with it. It is easier to
accept that the cause is external to us, but if we join this guilt to others that we may carry in our life, it
can become unsustainable.
It also doesn't help to say: "don't feel guilty" because we are putting them in a paradox: making them
feel guilty for feeling guilty! And not being able to stop doing it. Mothers have the right to feel what
they feel, to have us listen to them and, if necessary, confront their thoughts: Do you think all women
who have stress lose their babies? Is it possible that there are other causes that are currently unknown?
In the mourning process, there is often an additional loss: the lack of control.
Some people may have the feeling that they have no control over their emotions, and if they cause the
end of a pregnancy, this lack of control appears even more strongly. Precisely, we have to work so that
people acquire greater control over their process.
In some cases we have seen that some mothers, years ago, even in adolescence, had interrupted a
pregnancy. Guilt and doubts as to whether they did the right thing sometimes make them
uncomfortable to the point of thinking that they even deserve the current loss. In these cases, alluding
to psychological causes can plunge them into a pit that is difficult to get out of; therefore, it is essential
to be careful about what we say, since we do not know the story behind each woman.
But what do we do with the guilt?
Guilt is not a welfare state, but the opposite. It is part of the emotional and cognitive state that
surrounds a bereavement. There is no time limit, but it must be done.
However, we all know people who have been mired in guilt for years and years without being able to
get out of it.
Guilt is another defense mechanism that the psyche has to avoid facing raw pain when one is not yet
ready to face it. But it is not good to leave the person immersed in guilt for a long time, because he
will forget to walk his path and will end up feeling that guilt is better than continuing to work on his
conflicts in order to continue.
No one likes to suffer from guilt, of course. Psychologists speak of "secondary benefit" when someone
chooses a non-beneficial situation rather than evolve and take on the work involved.
We can review the situation that makes us feel guilty and see to what extent we were really
responsible for what happened. If we have a 20% responsibility, we will have to assume it and work
on the repair and apologize. If it is proven that there is indeed 0% responsibility, this should be enough
to dissolve the guilt, and if it is not, we will have to see what other psychic aspects are influencing the
person to choose to feel guilty (and be bad) rather than to grow and evolve.
Another way to rationalize guilt is to confront the person with the following reasoning: one is
responsible for an act if one had the power to change something.

Trauma: when grief becomes complicated

It is a mourning for the baby that is gone, but also a mourning for the pregnancy. Pregnancy is usually
a magical time for women, where everyone is looking out for them. Sometimes it has not even been
possible to share the joy of pregnancy if it has stopped in the first weeks. The woman's health may
also have been compromised.
When a pregnancy is lost, the worst fear has come true. In cases of abnormalities, one may come to
think that they have caused them or that in some way they are being punished. This feeling of guilt
may cause them to turn away from others who try to help them. It is necessary to address this feeling
of guilt, without denying it, but restructuring it.
Other untreated grief or grief that has not been expressed in its various forms can be reactivated by the
loss: a previous death, a separation, the lack of good parenting... An abortion or a subsequent abortion
after previous ones can open a Pandora's box: the whole process of searching for a pregnancy or
motherhood can come to light, with all its pain, with each of the losses together, with all that had been
silenced during the months, sometimes years, of the search process.
What makes a duel complicated?
These are some of the factors that can complicate a duel:
- A traumatic, sudden or unexpected loss.
- More than one loss at a time (grief overload).
- Previous complicated duels.
- A death "out of time" (such as the death of a child).
- Personal history: secure attachment, history of trauma...
- Social support.
In cases of infant loss, especially in the first weeks of gestation, social support is almost non-existent.
Social acceptance of trauma has much to do with psychological recovery.
The loss of a baby can cause devastating grief. If this grief is not accompanied, it can be confused or
turn into depression (they found that 9% of people who met the criteria for complicated grief also met
the criteria for Major Depression). But the loss of the baby can lead to Post Traumatic Stress Disorder.
PTSD can be caused by any event that generates a great emotional impact.
It is a disorder that involves three main groups of symptoms: intrusion, avoidance and physiological
activation. There are repetitive thoughts (why did this happen to me, it was because I was stressed, I
did not take care of myself), images that appear and cannot be removed from the mind, flashbacks (the
image of the ultrasound, of the gynecologist's gown, of the blood, of the hospital corridor, of the ward,
etc.) They are intrusive because they appear without being able to control them. On the other hand,
there may be avoidance of everything that reminds of the trauma: from the hospital, seeing pregnant
women or babies, the midwife or gynecologist, the baby's clothes or toys, even making certain
decisions that have to do with the loss, such as wanting everything to be over now. Physiological
activation refers to being more nervous, irritable, not being able to sleep or waking up and not being
able to fall asleep, having more fears, sweating, palpitations, restlessness.
There may be other elements that also have a great emotional impact within the loss. For example:
many women express their desire to finish now, once they know that the growth has stopped or that
there is no heartbeat, because of the impression generated by having a dead baby inside. If it already
causes a great shock to know that a loved one has died, the fact that they are inside your body can
become very unpleasant. It is important to understand and properly attend to this moment, warning of
the risks of haste.
PTSD may become more evident during subsequent pregnancies, with a simple ultrasound scan
becoming a triggering stimulus for an anxiety reaction.
A grieving process is a "normal" process: it is neither an illness nor a disorder and, as such, does not
require medical or psychological treatment. But we know that bereavement support benefits both the
woman and her partner and/or family. Of course, if a person feels they need professional intervention,
they should seek it, and it would definitely be indicated in cases of complicated grief.
If this process is not started immediately after the loss, we will find ourselves with deferred grief.
 CHAPTER 3
People need rituals

How useful are rites of passage?

The rites facilitate the learning and adaptation of man to different vital situations; among them, the
acceptance of death and the elaboration of the corresponding mourning.
The rites perform the function of accepting that the dead person is dead, while legitimizing the public
expression of grief.
People need rituals that channel our lives, that set guidelines, that give us a space and time to express
emotions and that help us assimilate what has happened, that differentiate one stage from another; that
show us that the days, although they pass one after the other with surprising equality, are in reality
different and unique.

Degradation rituals
They are those that aim to reestablish the lost status of a person by degrading the one who "ascended"
in status to put himself above him. They may be acts of denunciation or simply acts aimed at
repositioning one individual or another within the social hierarchy.
Clinical practices and, more specifically, certain professionals who use their status to violate those
who are actually their equals.
The clinical protocols that should be a guarantee of good treatment of the client are used as
instruments of power that end up contributing to the mother being deprived of her status as a "woman
with the capacity to give birth to a healthy child". By inculcating a vision of fertility in which
technology and a set of practices and techniques are necessary both to conceive and give birth to a
child, whether it is alive or dead, feelings of inadequacy are generated in women that make them feel
degraded and inferior. The conclusion reached by women, at different levels of consciousness, is that
she alone "cannot" and that she is somehow imperfect.
As women's fertile life is understood today, a woman who loses her baby in the womb does not feel
her status as a mother if it is not through the curettage that was done and the medical discharge paper
that corroborates it.
We need in our society other types of rituals that replace in some cases, and completely in others, the
clinical practices, that are the ones who give these women their status as mothers and who also help to
heal the wounds derived from the loss or the treatment received in the hospital.
People need rituals through which to identify ourselves as members of a tribe. Specifically in the field
of gestational mourning we find a series of social rituals that, although medically in principle they
collaborate in the process of the expulsion of the remains, neither culturally they contribute anything
nor do they help to go through the mourning that a mother and a father necessarily have to elaborate in
these circumstances.
The hospital admission, the medicine to induce labor, the analgesia to erase pain (and physical
sensations), the surgical process that "cleans" the uterus with the connotation that it was "dirty"? are
routines that truly prevent the secretion of the chemical-hormonal cocktail that the body has at its
disposal to prevent the subsequent depressive state, discharge and leaving the hospital "as if nothing
had happened". The woman who does not undergo a curettage because her loss was at such an early
gestational stage that the doctors considered it unnecessary, has to fight hard for others to believe that
what she had was really a pregnancy, and not a hallucination more typical of an abnormally hormonal
woman. The positive pregnancy test or the discharge report after curettage are the reliable proof that
you have indeed been pregnant, that you belong to the group of fertile women.
Thus, in these times when hospitals are beginning to realize that in case of gestational loss it is best to
intervene as little as possible, women, instead of being admitted for curettage, are sent home for
bleeding and ambulatory follow-up. This, which would be appropriate, when not properly
contextualized and explained, makes many pregnant women feel neglected and abandoned to their
fate. They should be helped to understand that they do not need surgery to feel their pregnancy and
their loss validated by society. They would need contact with other women who, having gone through
the same thing, help them connect with their inner wise woman.
The treatment received in the hospital is often more traumatic than the loss itself.
Receiving coldness when humanity is expected can be a great trauma, especially if the person is in a
state of deep vulnerability, as is the case of a woman in labor. The term "obstetric violence" is
beginning to be heard more and more in our society and, although it is not yet recognized as such in
our country, more and more women have decided to come out of their passivity and have denounced
the bad treatment when they were most vulnerable. These attitudes are also considered rites of
degradation, since they degrade those who have put themselves on a pedestal that did not correspond
to them, proceeding as if they were gods on earth.
One of the most subtle ways of violence is verbal violence: some words hurt more than a punch, and
when we talk about gestational losses, the type of vocabulary used (from medical jargon but without a
real adaptation to people who do not belong to this profession) is more often than not cold, aseptic, if
not directly provocative and terribly painful for the parents. Perhaps we need to reinvent a vocabulary
through which we can talk about lost children without reducing them to the status of "surgical offal".
In the book "The Empty Cradle" we believed that "an abortion" is not a concrete physical thing, that
which our soul child becomes when it dies in our womb and which we have to get rid of immediately.
An abortion is a process, something that begins at a given moment (when an intrauterine death occurs
or when, for whatever reason, the mother goes into ultra-preterm labor that will result in the death of
the embryo or fetus outside the uterus), the body continues with the inevitable delivery, the event
known as birth, and the return of the uterus to its cycles and routine.
A miscarriage is a set of processes included within the female psycho-sexual, emotional and spiritual
cycle that occurs naturally in the body-mind-spiritual of a pregnant woman that results in the birth of
the baby in its development being her death the cause or consequence of it. This process will occur
regardless of whether or not medical intervention is involved.
You don't say goodbye to someone you love who is gone forever and that's it. It is a process in time:
the friend prepares to leave, he notifies us, we set a date for a farewell dinner, we prepare the clothes
we will wear, the places we will go to, the gifts we will exchange, the dinner is prepared, the day of
his departure arrives, we accompany him to the station, we say goodbye for the last time, he leaves,
and we are left with the memories, the common photos, the gift we receive and the mourning road we
have to travel while our friend leaves.We say goodbye for the last time, he leaves, and we are left with
the memories, the photos in common, the gift we received and the road of mourning that we have to
travel while our heart, our mind and our spirit are getting used to the idea that it is like this: he is gone
and there is no going back, we will never see him again.
What we have done to say goodbye to our friend is a farewell ritual. If it was abruptly and there was
no time to say goodbye, the ritual will have to be done later, perhaps alone, with his memory and
photos, but it will have to be done sooner or later.

Farewell ritual in the case of gestational bereavement

The ritual is part of the process that parents need to do over time to say goodbye to their child.
The "expectant treatment" is the most powerful farewell ritual that exists, since it is the body, with its
times and wisdom, which sets the rhythm and the times for the farewell. If there was no possibility of
doing so, it is important that, afterwards, a ritual is elaborated to simulate the times that our soul needs
to accommodate to the pace of rhythm that our modern society imposes on us.
Rituals are a tool that helps the brain to reprocess all this information, taking the necessary time to do
so, helping at the neuronal level to make the necessary connections.
Rituals make the two brain hemispheres begin to exchange information, making it easier to reprocess
the sensations, emotions, images, smells, data, words... associated with the fateful day and helping to
dilute the trauma that may have been generated at first.
In gestational mourning, rituals will be useful to say goodbye to the baby, to give the baby an identity
and a place in the family and in society, to help the parents find their own place in the tribe and to
elaborate the mourning.
To give the baby an identity and a place in the family and in society: when a relative dies, we have
photographs and memories with him/her, with other relatives, him/her alone... When a child dies in the
womb there are no memories or photographs. Maybe there's still the pregnancy test, an ultrasound,
some clothes that someone gave us...
It is important to keep all this evidence of your existence, to create what we call a Memory Box. Yes,
also for such early losses. You can write them a letter, keep a knitted blanket, maybe a small one,
according to his/her size, but enough for him/her. If there were other children, they can draw a picture.
You can create a handicraft to remember their presence and their passage through this world. Creating
this memory box can be a ritual that involves the couple and other children if there are any.
Grandparents or other family members may also participate if they wish. You can prepare the gifts, the
box and set a date when everything will be collected and stored.
A memory box does not have to remain closed, you can add things, you can open it and remember
with affection the good moments that have passed, as we do with the family album in which our
deceased relatives appear.
When a perinatal death occurs, more and more often in hospitals, parents are offered the possibility to
take pictures, to be photographed with him/her, to dress him/her, to bathe him/her, to show him/her to
the close family... It is a powerful ritual to be impregnated with the presence of this dead baby as
important for his/her parents as their other children. It is a memory that lasts a lifetime.
But what do we do when the delivery is so premature that there is no baby to photograph? You can
also save an image of the small embryo if you collect it, or of the small one even if it has not measured
more than a few centimeters, if you have enough presence of mind to do so. If this possibility has not
been given, you can always resort to other means.
Grieving: a ritual in itself is healing. While it is not a magic formula for successfully overcoming
grief, it can be an extra help in processing the emotions that will arise. They can be used as a rite of
passage from one phase to another, or if you feel you are stuck, use it as a support to continue on the
path.

Who participates in the ritual?

A ritual can be attended by as many people as the person or persons who organize it want to
participate. You just have to take into account for whom it is made, because it can be an intimate act of
two or a social gathering of many people. It is necessary to decide beforehand what is going to be and
who is going to be invited.
Different types of rituals that can be adapted according to circumstances, situations and personal
choices:
- Between the mother and the father: you can make a ritual of preparation to receive the baby, e.g.
have a special blanket or blanket, or if it is too small a T-shirt of a doll, prepare a little box ....
The mother will go through her physical process of loss, which is the greatest ritual, especially if she
lives with expectant management. Respect the times that the body needs, decide whether it prefers to
be in a dark place, in semi-darkness, with light. Decide if you want to put incense or burn some
essence ... are often times when external odors can load, preferring the smells of the body itself, the
blood ... Maybe the woman wants a massage on the kidneys or get into a bathtub with hot water to
soothe the pain or maybe not. Just as in childbirth, the wishes of the laboring woman will be respected
at all times and she will be accompanied in her transition with respect and empathy. For the father,
who does not have to go through the physical process, perhaps accompanying his partner is a powerful
and effective ritual. Although at that moment his wishes take a back seat, it will be appropriate to take
him into account and invite him to participate as much as possible. He may want to be the one to pick
up the baby's body and cover it. It is important to know what is going to happen in order to be able to
choose what you want to do and what you don't want to do.
The best gesture a newborn baby can receive, especially if it is a premature baby who will die in a few
moments, is to remain on its mother's chest, skin to skin, heart to heart. It is the best farewell that can
be given to a human being. This ritual can be adapted in case the baby is stillborn but you still want to
explain that as the son of so and so, he is a person even if the law does not contemplate it that way and
has a name.
- Drinking a glass of water on an empty stomach every morning, as a symbol of purification of the
body before the new day begins, charging with energy to undertake the daily task.
- Cooking a special dish.
- A tattoo...
- To explore artistic aspects that were always put aside for another time: painting, writing,
studying... as a rite of passage to another kind of life in which to do what one did not allow oneself to
do in the past.
- Make a ring, bracelet or other jewelry with the baby's name engraved on it.
- Sometimes a pregnant woman feels like buying something for her child but puts it off until later,
and once the baby dies there is no reason to buy anything. It could be purchased a posteriori as a
souvenir and transitional object for the mother.
- Tears of milk: if the baby was old enough for the mother to have milk, it can be expressed with a
breast pump and donated until the woman feels it is time to wean. Offering this colostrum to other
children in the family who are still suckling can become an unforgettable ritual. The moment of
extraction or of feeding another child the milk that was destined for the little one who is not is a very
deep and tender experience.
- There is a ritual that consists of writing a letter to the baby (or drawing a picture or whatever you
want to express), tearing it into a thousand pieces and carrying them in a special bag with you in your
purse. It is a matter of getting rid of the pieces little by little, choosing the places where they will be
left, or not. The paper and what is expressed on it symbolizes the baby who has left abruptly. By
gradually distributing the pieces over time, the mother (or father or whoever needs the ritual) is given
time to say goodbye a little at a time. A suggestion would be to burn the last ones in a ritual on the
date that would have been the probable date of delivery, or on another special date when you want to
close this ritual of the letter in a thousand pieces and the farewell of the baby.
- Write a letter to the baby to say goodbye, thank him for the time he spent with us, give him
permission to leave, express your anger for not having stayed longer, tell him how much you have
loved him and will love him... The verbalization of feelings makes it easier to become aware of the
situation.
- Prepare a souvenir box: go out and buy a souvenir, either for the parents themselves, for the baby
or for a relative.
- Decide whether or not to name the child.
- Share the couple's expectations for the future: what they will do next, the sexual relations during
that time, the support they will give each other (through massages, caresses, lighting a candle and
staying in the dark, cuddling on the sofa...).
- Write a letter to the baby or write your feelings about the baby that is gone. Put the writing inside
a helium balloon and launch it into the sky at some place and date.
- If there are more children, the siblings can also write a letter, draw a picture, collaborate in the
creation of the memory box and reminders, make a personal family book that includes the little one...
- In the case of gestational death of a twin, after the birth of the living twin, the placenta of one and
the ashes of the other can be buried in two trees, two rocks.... In the case of a twin gestation, it would
be important to keep in mind that the surviving twin will also need to say goodbye to his or her
sibling; in due course, this sibling can visit the place where the ashes are and make his or her own
offering, receive an explanation of what happened.
- Regarding the family, a meeting could be held in which an exchange of gifts for the baby or
mother, for the father, grandparents... After all, everyone has lost something: a child, a grandchild, a
sibling... They do not have to be expensive gifts; simply a symbol of shared time and the happiness of
an imagined future. Perhaps it would be interesting to do it in a therapeutic context in which a
psychologist can help to manage emotions; in many families it is difficult to share with those who
would have been the grandparents the strong feelings of grief and helplessness, which does not mean
that they do not feel pain for the loss of their grandchild. Perhaps it is a ritual to be performed on the
anniversary of the loss, when the mourning is more mature and the people involved are more
recovered.
In the case of families in which the loss is denied, you can try to invite, and if the answer is negative,
you can celebrate the dinner leaving the empty chairs of the people who are not there. These chairs
symbolize the mourning that will have to be carried out by the people in your family who will not
accompany you in the process. Just as parents change after the death of a child, so does the whole
family, and sometimes, even if it is hard to see how the game board looks, it is important to accept this
and include it in the mourning process. This would be another ritual to be performed under the
supervision of a therapist because of the high emotional content it can mobilize. The image of the
empty chairs alone is already very powerful.
If the couple feels that they have lost a family member because of their refusal to participate in the
mourning for the baby, they will have to work through that mourning as well. You can put an empty
chair and talk to him, or write a letter to him, read it aloud, burn it and throw the ashes in the air.
- Regarding the extended family, they may be invited if a mass, the equivalent of other religions or
any other act of farewell and/or remembrance is celebrated. Reminders can also be prepared with a
photograph of the child, an ultrasound image, a footprint or handprint or any other image that
represents him or her, or a poem...
- With respect to friends and the rest of the community, you may also be invited to mass or the
religious equivalent to which you belong.
It is possible that a friend bought something for the baby at the beginning of the pregnancy and upon
learning of the loss did not deliver it; for the parents it is usually an emotional and grateful detail to
receive it, or even if it is something that has been purchased after the fact.
- Regarding the face-to-face and/or virtual support group: increasingly, the Internet is filling the
communication gaps that we see every day through the so-called "global tribe".
The feelings of cohesion, unity, recognition of the children... the feeling of being part of a tribe...
greatly favors the acceptance of the situation.

Creation of the ritual

We want to create rituals through which to channel the grief of parents, socially and individually,
creating spaces and times in which to mourn the child, introduce him/her to family and friends as a
child and member of the family and give him/her an identity and a place in the family history.
The ritual begins from the very moment it arises in the minds of those who are going to organize it.
Although a ritual can accept many variations, we will give some common points from which to
develop the most appropriate for each person or family:
- symbols: It is the smallest unit that composes a ritual. It can be an object, a read or recited text, a
special place, a specific action...
The components of a ritual to be taken into account will be: the symbols, the place where it is
celebrated, the day and/or time, the action, the people invited, fixed variables that are decided
beforehand and others that can be left to improvisation.
For example: the blanket knitted by the grandmother, around this piece, handmade, unique and
precious, a ritual can be created in which the mother can feel accompanied, using it as a transitional
object that helps her to make the transition until she feels that she can separate from her little by little
and with her, also separate from the baby and let him go.
Another thing that for the mother can be very symbolic is the clothes she wore during pregnancy.
- Elements derived from the senses: often, the characteristics of both are intermingled, such as the
taste and smell of a meal celebrated as a ritual.
- Tactile elements: a massage, hugs, caresses, exchange of gifts and souvenirs... A transitional
object such as a blanket, towel, cushion, stuffed animal... to be used in low moments, to be able to hug
them, cry on them, sleep with them...
- Sound or auditory elements: music, nature sounds... Depending on the place where the ritual is
celebrated, especially if it is outdoors, there will be some sounds or others...
- Olfactory elements: smells of nature, of essences, the body's own smell...
- Visual elements: playing with light, candles, making squares with the ultrasound image, photo
album, souvenirs in which the name of the child is painted or bordered.
- Taste elements: family or couple meals.
- The environment: Where will it be held? At sea, in the mountains, at home in a restaurant, in a
therapist's office?
- Timing: When would it be appropriate to perform a ritual?
- In mourning the death of a baby in the womb, we encounter 3 potentially important and
emotionally disturbing dates: the probable date of delivery, the date when the pregnancy was known,
and the date when the pregnancy was lost; the latter can refer to 2 moments: when the parents learned
that the pregnancy was arrested and when the bleeding finally appeared. It is worth bearing them in
mind, as it is likely that there will be setbacks in the mourning process during these anniversaries:
particularly emotional days and certain physical symptoms that will be more intense. Creating rituals
around them is a way to give yourself permission to live them in a more conscious and healthy way.
The following are a series of dates on which many mothers have observed that they feel sadness again
as a reminder of the death of their babies, and also the invitation to prepare a ritual around those that
are considered appropriate:
- If there has been expectant treatment: it is already a ritual, the most powerful one, a day will be
chosen to remember it.
- If there has been curettage: the time of physical farewell. A ritual that connects with the most
intimate and sacred part of the mother and father will be necessary.
- Farewell with the other siblings, if any.
- Farewell with family and friends as long as there is a positive atmosphere.
- The days on which the months of pregnancy would have been completed.
- The day of the probable delivery date.
- At one year, at the time the woman became pregnant.
- A year later, when they learned that the pregnancy was fated.
- At one year, when the bleeding and loss of the physical remains occurred.
- When the woman becomes pregnant again. It would not so much be a celebration as a series of
them, since becoming pregnant again means welcoming a new child and, at the same time, another
farewell to the one that left.
- When another sibling is born: some mothers feel that with the new child they "neglect the
previous one. It will be necessary to continue giving space to the baby that left, and make sure that the
one that is not left unattended is the little one that is born.
Other ideas:
- Symbols related to the 4 elements:
Fire (burn the remains or farewell letters, light a candle and let it burn out in time).
Earth (keepsake box with letters, pregnancy test, ultrasound, souvenir, tree planting)
Water (reading poetry on the seashore or river bank, throwing ashes...)
Air (spending time in nature, launching helium balloons into the sky...)
- To do other things that really mark and favor the end of one stage and the beginning of another: a
long trip, change of image, explore artistic aspects, study, change of house, change of job... Many
times, a loss, as a vital crisis that is, leaves in evidence in the couple irreconcilable conflicts that end
up breaking it. Starting a new life alone would also be a symbol of the beginning of another stage.
A ritual is not something magical that will give us back that which has departed, nor will it perform
the miracle of elaborating the work of mourning that each person has to do.
But it can relieve us in such a hard moment and help us to emotionally manage the situation.
 CHAPTER 4
The environment
If what you are going to say is not more beautiful than silence, do not say it (Arabic proverb).

Many couples encounter unfortunate comments that contribute to further discomfort.

The father
The pregnant woman is the one who physically experiences the loss, but the father faces two
situations: the loss of the baby and the concern for the loved one. There may even arise the fear of
losing her too, the one who was, and also a real loss. This fear may not be objectively motivated,
because there was no risk to the mother's life, but the couple may experience it in a very real way.
In the past, grief was different in men; today, fathers can feel more of a bond with their developing
child than their ancestors did, thanks to new imaging technologies during pregnancy and the wealth of
information available about the first important weeks of embryonic development.
The studies and articles published on gestational loss deal with the discomfort of mothers, but little on
the impact on fathers, and much less on cases in which the partner is another woman. In the support
forums where grief experiences are expressed in great detail, the presence of men is anecdotal, and
their feelings are an "interpretation" of the women, not their first-person voice. Perhaps the couple's
grief is silenced from the outside, by society, and from the inside, by the individual himself, for
cultural, educational, social reasons...
Parents are in mourning after a perinatal loss: they suffer shock, anger, emptiness, helplessness and
loneliness, although guilt does not appear as the first response. It appears that the response is less
intense than in women. They comment that this may be due to the role of caregiver that is socially
given to them.
Each person reacts in a unique way to a loss; it depends on the bond with the baby, and we are also
aware that men and women, by physiology or education, deal with grief in different ways. In general,
if the mother tends to introspection, the father tends to action. For example, they may force themselves
to leave home, to recover their former life soon...; in this circumstance, the woman often feels
overwhelmed, and tends to interpret a lack of mourning on the part of the man who is her partner,
which in turn can become a source of conflict in the couple. We would be faced with two forms of
grief: one more inclined to go out, to be distracted, to do, and the other to be recollected, to focus on
one, to feel. The communication, the capacity that each one has to reach the other and to dedicate time
to him/her will often benefit the union, and the couple will be strengthened. Failure to achieve this
could be a major gap for the future of the union. When the two manage to "find each other", they
understand how important it is not to isolate themselves from each other, each living their grief
separately.
It appears that the greater the disparity in the couple's grief reactions, the greater the negative effects.
The woman sometimes suffers for the baby, for example, in case of termination of pregnancy. The
father suffers for the baby and for the mother. When it all passes, the man may be relieved that he still
has the woman he loves. And this relief may be misunderstood by the woman, reproaching her for
being less sorry for the loss of her baby.
Bereaved couples resort to the following strategies:
- Acceptance of differences: some couples see the positive side of grieving differently: "he pushes
me out, she helps me focus on what is happening to us".
- Spending time together. In the wake of a loss, many couples spend more time together, some
sharing their feelings and thoughts.
- Allow time to be apart. While some women prefer to share with support groups or see a therapist,
some men turn to sports as a tool for assimilation.
- Find the common point of their duels.
- Caring for each other, creating positive memories.
- Healing takes time
In the vast majority of cases, the loss of a baby a few weeks old occurs in a heterosexual couple, but it
should not be forgotten that there may be other cases, such as women who have decided to become
single mothers. Your grief will be lived with some slight differences, for unless you have a family or
"tribe" with strong ties, you will not have the advantages of alternating grief states or the
disadvantages of reproach.
We also take into account the increasingly visible case of female couples who choose to be mothers:
this situation carries very different connotations compared to heterosexual couples because, as a
natural rule, both can procreate. This fact gives the loss some very special conditions that would need
an in-depth study: both can become pregnant and both can breastfeed their baby.
Pregnancy loss can therefore have very peculiar repercussions. One of the biggest difficulties when a
woman loses a baby is seeing other pregnant women and other babies. But, what happens when in the
grieving process for the lost baby the one who is pregnant is the partner herself?how is the grief in
these couples?

The couple
A loss is a major life crisis and, as such, directly affects the couple. Some explain that the loss has
brought them closer together, especially when they have been able to do psychotherapeutic work
together; others have drifted apart, to the point of separation.
When grieving, sexual relations are directly affected. In addition, physically there may be some
impediment to penetration, especially in the process of loss of the remains or after curettage. Sexual
relations are intimately linked to the fact of reproduction itself, which could have been affected even
before the loss, since it is customary to control them for the exclusive purpose of using fertile days.
Our experience is focused mainly on the feelings of women, who are the ones who resort more to
forums and professionals; in this aspect, men are still a great unknown due to their less emotional
expression.

Let the children approach

What about the children? What about them? Should we spare them the pain and suffering and not tell
them about the loss? Maybe they didn't even know about mom's state of good hope, the aunt's... should
we tell them?
Minors, of any age, have the right to be informed of what is happening in their families; they have the
right to take an active part in the process and to be encouraged to take all relevant actions so that their
grief can be adequately prepared. No one should take away this fundamental right.
Children have a high emotional intelligence and are especially good at reading the non-verbal
language of adults. Communication specialists explain that verbal language represents 7% of a
communicative act: therefore, children clearly perceive that something is happening, and may
misinterpret it due to lack of information. For them, it is very helpful for the elders to put words to
what is happening and what they are sensing going on around them. They may think that it was their
fault, that it is a punishment... Infinite erroneous and harmful interpretations that in their fabulous and
creative mind can do a lot of damage and have consequences for a good psychic development.
It is important to talk to children no matter how old they are. Many have lost a sibling, a cousin or a
dear and long-awaited friend. Their reactions attest to how they are able to understand the parents'
grief and pain. In many cases, more than adults, they know what to say and how to act. All reactions
are normal; what is abnormal is what happened: that a baby dies on the way to life.
When a child is able to draw a picture for his aunt and uncle on Father's Day because their baby will
not be able to do it, and he has the idea of doing it on their behalf, he shows an exceptional ability to
act, to express what he feels and to support these bereaved parents in an exemplary way. When a child
of a few years old, without anyone having told him/her anything about the loss but knowing about the
pregnancy, is able to point to his/her mother's belly and say: "It's gone, isn't it?"It is essential that we
tell him the truth, that we do not deny it on the assumption that they do not know about the time, that
the mother will get pregnant soon and the child will not realize that it is another pregnancy, he will not
notice it and thus he will be spared a great sorrow.
It is necessary for children to be able to trust us, the adults, in joys and sorrows. To participate in the
grief for the loss of an expected and desired baby is to make evident to the other children of the family
the value they have for their parents with facts, not with speeches. And it is a great apprenticeship: of
death. These children will grow up, beget and carry in their luggage a wisdom that they have been
granted to unfold, they will not have had to silence and make it appear that they did not see or did not
realize.
In general, children are kept away from death, from hospitals, from farewell rituals, from intensive
care units until they are 12 years old, but babies, children know and understand everything.

The close and extended family

When a woman does not feel understood or accompanied in her grief by her closest relatives and
decides to communicate it to them, many times these, instead of understanding the situation and what
is being asked of them, feel attacked and choose to demand that the mother be well as soon as
possible, because their attitude, that of living the path of grief in depth, disturbs the family harmony
and their tranquility, their daily life.
The bereaved partner may feel that their people have failed them, that they have not received the
support they needed from them: parents, siblings, close friends. They need time to express their grief
so they can incorporate this difficult time into their lives and move on.
Sometimes what disturbs grief, or can pathologize it, is not so much what happened as the unfortunate
attitude of professionals and the environment. A common reproach in cases of misunderstanding of the
grief and bereavement experienced by parents of a loss of a few weeks of gestation is that "they do
nothing to be well, that they recreate in their pain". The mother is usually advised to seek therapy or
medication, a measure that will "solve" the problem without any change or alteration for the rest of her
family and/or friends.
In general, the relatives who most impede their healthy expression of grief are those who would not
have allowed themselves to express their own grief for the death of an intrautero baby. If one has not
resolved one's own grief and has turned the page by silencing the pain, not living the grief, avoiding it
or drowning it, one may consciously or unconsciously be expecting or asking the same of one's
daughter, sister or friend and is likely to react hostilely or feel especially affected when this close
person mourns with all his or her expression of grief.
The emotions of others mobilize our own, especially when wounds are open. Whoever pretends to
accompany the pain of another person with unresolved grief will not be able to help in an adequate
way, and it may be especially painful or traumatic for this person.
When a baby doesn't make it to its mother's arms, it doesn't make it to the family either. And everyone
is affected, whether they realize it or not, whether they want to see it or not. The problem with not
wanting to see it is that it implies an intolerance to the mother's affection, because it implies feeling a
pain that not all family members are willing to acknowledge.
In these cases, it is important that each bereaved couple knows how to measure their own strength to
face or not to face these family conflicts in order to focus on what they urgently need, which is to live
their grief, attend to their needs, take care of themselves, listen to each other, pamper each other, be
patient, let their pain be expressed freely... in a place where it is understood and validated. The best
time to emotionally re-educate society is not in the midst of one's own pain.
Many people become emotionally blocked by the news of the loss of a baby, including those close to
them. They do not know how to act. That doesn't mean they are bad people, it just means they don't
know any better. It is the mother who has had the loss who encounters that lack of knowledge or that
lack of emotional intelligence. Perhaps they have been fortunate enough not to experience something
as painful as what she is experiencing, or perhaps they did not allow themselves to experience it, and
therefore have convinced themselves that the best thing to do is not to give value or space to this
experience, but to hide it, to pretend that nothing happened and not to allow themselves to feel.
When our society does not know how to handle something or is afraid of it, it ignores it and pushes it
aside.
When on the path of life I cannot move forward, do not take advice. Give me your hand and let me
cry.

CHAPTER 5
Attempts

Loving the time of attempts

We are so blind to get there that we are missing the rest of the journey (Beatriz Martinez Varela).

Gestational losses are sometimes associated with difficulty in becoming pregnant again. It can take
months, a whole year, sometimes even longer before the pregnancy test is positive. In these cases, all
the monthly losses of receiving a menstrual period month after month are added to the mourning.
What is a pleasurable act becomes almost an obligation. Half of the month is spent waiting for the
fertile days to arrive, and the other half in an anxious wait to see if that month is the definitive one.
The onset of the hated period culminates a cycle of ongoing anxiety and distress.
To finish off the picture, there is always someone well-meaning to remind the would-be pregnant
woman that all this anxiety is not exactly the best thing for getting pregnant and that, in any case,
obsessing about it is not a good thing. We have a breeding ground in which guilt is assured.
Perhaps it would be necessary for this couple overwhelmed "by the obligation" to achieve pregnancy
to open a therapeutic process to help them to effectively reduce anxiety: to put in place the emotions
for the lost baby and those generated by the current situation. Neurobiological therapies are showing
very good results in cognitive and emotional information processing.
It would be necessary to see if physical reasons could be hindering this pregnancy. Sometimes a
change in diet works miracles. It is also interesting to assess whether the partners know the woman's
fertile days. Each body and each cycle is different, and not all women ovulate on the fourteenth day of
their cycle. There are natural methods and urine tests to know which would be the right days to
attempt fertilization.
Waiting for a positive result can be very stressful; moreover, a couple lives immersed in a social
network whose people take it for granted that "it's time for them to have a baby", and do not hesitate to
tell them so actively and passively whenever the occasion arises, without any tact or respect: "When is
the baby due?"What are you waiting for?", "I already had 4 children at your age"....
The therapeutic technique of defocusing can be very effective in these cases: when we have a problem,
we tend to dive headlong into the search for solutions, put everything else aside and race against the
clock to find an answer.
De-focusing is about trying, as much as possible, to have other goals that also fill your life, stories
other than negative pregnancy tests. Allow yourself to laugh, "make humor", remembering that the
true essence of sexual relations is to share pleasure. Rescuing the passion for life in its broadest
sense...

Assisted reproductive techniques: losses and multiple losses

Many couples spend years trying naturally for a pregnancy, after which they turn to assisted
reproduction, either artificial insemination or in vitro fertilization (IVF). Fertility treatments are almost
the last chance to achieve pregnancy.
In addition to the economic cost (in private health care), the physical cost of the treatment must be
faced: pharmacological stimulation of the ovaries, ovarian puncture, implantation, controls... Many
women complain about the side effects, about how exhausted they end up and how the process affects
them emotionally: everything is measured, controlled, as if they were passively part of the process
itself.
The IVF process itself is very stressful for couples, especially for women. It seems that the most
anxious periods occur on the day of the ovarian puncture, the day of the embryo transfer and the
fifteen days of waiting to know the result after the transfer. This is why, in the face of certain failures,
many women consider giving up.
Every attempt at insemination of fertilization is a loss. When finally the embryo does not implant well,
or the process is stopped after a few weeks, it is not only a loss, but the exponential sum of each of the
rules, attempts, inseminations, fertilizations... It is a deep mourning, accompanied by an emotional
cocktail of guilt and anger. It could be the loss of the last opportunity, of so many years focused on
conception, of economic investment...
Some women will feel the injustice of not getting it after having done everything: dietary changes,
alternative medicine, new lifestyle...
IVF results in the creation of several embryos that are implanted at the same time in the hope that,
statistically, one of them will be successful. But there may be several cases: that some of the embryos
do not implant well and are lost while their "little brothers" continue, or that in case they all implant
well, a "selective fetal reduction" is chosen to be performed. These are complex situations that can
create ambivalent feelings: those who have the most opportunities are thought to move forward and
the rest are sacrificed. Such ambivalence can be difficult to bear and deal with, because the joy of
some cases is linked to the bitterness of the rest. In these situations, it can be of psychological help to
give an entity to these lost embryos and perform a ritual as with any other loss.

Cycles
There is something in which medicine has been pigeonholed for a long time: in considering the
woman's body as something imperfect and, therefore, sick; and, as such, it is necessary to cure it and
help it in its irregular and impure processes so that it becomes as similar as possible to the man's body,
which is still considered the reference model of health. History has wanted to forget the thousands of
years in which women were masters of their lives and their cycles; beings, like men, complete and
perfect in themselves.
When a girl is born, she already carries within her ovaries the eggs that will mature in her adult life.
With menarche begins her fertile time, which will be marked by menstrual cycles: every 28 or every
30 or every 40 days an ovum will mature inside her, which will culminate and die if it is not fertilized,
leaving the body through menstrual bleeding. This will be repeated every month, as long as you do not
become pregnant. If you become pregnant, these cycles will stop, giving way to another time marked
by other mysteries: pregnancy, childbirth, upbringing...
There will come a time when a woman will reach climacteric, also known as menopause, when the
cycles will cease and she will enter another period.
Wisdom is present in all stages of a woman's life. It is this wisdom that we have to recover. Our bodies
know what to do at all times: they know how to ovulate, gestate, give birth to living and dead children,
breastfeed....
Each feminine archetype teaches us something. Each phase of the moon reflects a part of the immense
and rich prism that is woman. Only by discovering and healing each of our inner wounded women will
we be able to recover and enjoy the gifts that our body offers us in every moment of our lives.

Breast ages
The biological age of the mother who has suffered a loss often increases the anguish for the passage of
time, the uncertainty of each passing day is worse to conceive and give birth happily. The social and
cultural pressure on this issue adds anguish to the recovery time of a mother who feels she is running
against the clock.
Michel Odent says that women are always considered by the system as imperfect for this function: too
short, too thin, too full, too narrow, too young, too old, etc. They are almost never at the optimum time
to become pregnant and give birth.
If nature favors the perpetuation of the species, a woman who can become pregnant, no matter how
old she is, it seems logical that she should be able to give birth and breastfeed. A girl who does not
menstruate cannot give birth because her body has not made the necessary changes to adapt to possible
motherhood and does not release eggs; a menstruating girl can. In fact, changes for adequacy already
start before menstruation.
A woman over 40 who ovulates may want to become a mother, and the decision is hers and legitimate.
We should not sacrifice this desire for exogenous or theoretical reasons. We face enough impediments
to motherhood without leaving it to age alone. It is nature and not man who determines whether it is
suitable or not.
Equalizing the correct age for childbearing is unfair because not all women start the changes at the
same age. And even more difference in the age at which each woman starts menopause: women stop
ovulating at very different ages: there can be fifteen years of difference from one woman to another,
and in this time you can try to be mothers many times if that is the desire.
The optimal age set by maternity manuals, from 20 to 35 years, is an exaggerated prophylaxis. A
woman's reproductive life is limited by nature, there is no need to limit it further.
A woman becomes pregnant and gives birth to a healthy baby boy or girl at the optimal time when she
does, not when the manuals say so.
Our society views motherhood beyond the age of forty with reprobation, but the last children of our
multiparous grandmothers were born at this age, and their physical conditions were, in general,
because of their harder lives, worse than ours, and their life expectancy was shorter.
The uterus is a powerful muscle that has a prominent role in pregnancy and childbirth, it moves
exercising it with the movements of menstruation, with orgasms, with belly dancing, etc.. And this fact
can lead us to consider that a uterus at the age of 40 can be much more exercised than at the age of 20.
The vast majority of women who lose a baby feel that they have a pending subject, and sooner or later
they are encouraged to try again. Many of them succeed, and despite all the fears, uncertainties and
anxieties that surround a pregnancy after loss, they finally get to hold their baby in their arms. It is
obvious that these mothers who are mothers after one or more losses are older than when they lost
their babies. So how can we go about adding so much angst to all women with the age issue?
Albert Einstien said that "when the laws of mathematics refer to reality, they are not true; when they
are true, they do not refer to reality".
No one can know at what age a particular woman will have a successful pregnancy and delivery. No
one.

CHAPTER 6
Time to decide

Another great taboo to be silenced is the so-called therapeutic abortions.

A pregnant woman within the first 22 weeks goes with her partner to her gynecologist's office for a
routine visit. An ultrasound was performed and a malformation was detected in the baby that was
incompatible with life. The medical recommendation is to terminate the pregnancy, the sooner the
better, if possible the next day. This situation is a major drama that is repeated every day in
gynecological consultations.
We can think of it as a couple in the process of creating or increasing their family. Perhaps they come
from a long process of assisted reproduction, have gone through other early gestational losses and are
happy because they passed the critical period of 3 months. Perhaps they were fortunate enough not to
experience the bitterness of loss before and come with the innocence and faith of any couple in their
first pregnancy. The news came as a cold shower. "It can't be, it can't possibly be happening to me...".
Meanwhile, the doctor discusses details, medical jargon that the parents do not understand; perhaps he
does not even address them, they talk, they comment among several doctors. Once at the table, she
explains that the baby has a serious malformation and will not survive outside the mother's womb, for
example, that it is best to terminate the pregnancy so that the psychological impact is less for the
mother and for everyone. It could be that already in a previous visit something strange was seen and
certain tests were recommended to confirm or reject the hypothesis. These parents will come to the
consultation hopeful, believing in the miracle that will make it all turn into a bad dream.
The couple is in shock, and the doctor urges them to make a decision. It is not the most appropriate
time. Few couples are capable of stopping to think and taking their time (the time that anyone would
take with an adult person on the verge of death to make the decision that will mark their life from then
on), to decide what to do next. The very hormonal discharge that the body generates in a situation like
this causes them to be guided by the supposedly expert advice of the doctor, who tries by all means to
put an end to the situation in front of him.
It would be interesting for the physician to have enough theoretical training and personal therapeutic
work to stop to see and listen to the people in front of him. There can be many reactions: crying,
disbelief, denial... The couple needs space and time to begin to say goodbye to the baby, to the dreams
they had forged, to the life they were going to live together. They need time to make a decision that
respects the baby, themselves, the mother and her body... Abortion should be one of the options, not
the only one. Maybe some couples want to have that baby and say goodbye the moment they have to
leave; these parents should also have the right to live their pregnancy with the respect of the
professionals who take care of them, without the stress of a thousand tests, knowing that time is
running out but that they still have time to say goodbye to the little one.
At a time when these parents were not ready to decide anything, they have been urged to make one of
the most important decisions of their lives. You may be haunted for the rest of your days by the
specter of "what if... I had asked for a second opinion?". Parents are faced with an important decision:
to continue or terminate the pregnancy.
After a diagnosis of malformation or genetic alteration, a consultation session would be ideal to review
the results and be able to decide with all the information available. Before making the decision, it
would be advisable to have the following questions resolved:
- Are you absolutely sure of the results?
- Can this condition be corrected after birth?
- Can prenatal surgery be performed to correct the problem?
- What are the chances that the baby will survive?
- How can this condition affect the mother's health?
- How can this condition affect the baby's health?
- Will there be physical disabilities?
- Will there be mental disabilities?
- After birth, will the baby need to undergo multiple surgeries throughout its life?
- What level of performance can we expect?
- How will this affect subsequent pregnancies?
- What are the chances of this happening again?
To ask and answer these questions requires time, which sometimes is not available. When making the
decision, certain aspects should also be taken into account, such as:
- The prognosis itself: incompatibility with extra-uterine life, reduced life expectancy, death at 2-3
years of life, reduced quality of life due to mental or physical disability...
- The reproductive life of the couple: previous infertility problems, previous gestational losses...
cases that, for example, could accept a baby with Down Syndrome as the last hope to have a child.
- Work and economic situation of the couple: impossibility of attending to the special needs of the
baby, one of them having to leave his/her job to look for resources, take care of the baby at home,
follow a treatment...
- The impact on other children in the family: a child with special needs may require more
emotional involvement, which is subtracted from the sibling, if any. Although it can also be
considered from another point of view: having a sibling with a disability can increase the sensitivity of
others to people with different levels of abilities. Some parents already have one child with a disability
and may wonder if they will be able to cope with a second child with special needs.
- The impact on the child: many couples may wonder if this is the life their baby deserves, and
consider the physical and emotional suffering it will entail for them. Unfortunately, there is no way to
foresee whether certain disorders will lead, for example, to further surgical interventions or not.
- Religious beliefs: some people may need to consult their spiritual guide.
- Personal beliefs: whether or not to expect a life to end naturally, whether or not a life should be
interrupted depending on the quality of life it entails, whether or not to accept a child's disabilities.
- The reactions of family and friends: it is difficult to predict how the environment will respond.
You may be very fearful of receiving certain questions or criticism. Some couples choose not to give
details so as not to be judged, simply saying "we lost him".
- Repentance: there can always be a doubt as to whether or not it was done right. This is a common
response. In these cases, it may be useful to keep in mind that: "that decision was the best decision
under the circumstances.
It must be taken into account that these mournings involve two mournings at the same time: about the
lost baby and about the child that the couple hoped to have.

Continuing with the pregnancy

Once the decision is made to proceed with the pregnancy, the couple should take into consideration
the following aspects:
- The birth plan: having a baby with abnormalities may require some attention, although it does not
necessarily have to be a complicated birth...
- The funeral: organization, wishes, guests, arrangements...
- Communication: ideally, we should tell people anything that makes us feel comfortable. Above
all, the well-being of the couple must be sought.
In the meantime, we have to go on with the day-to-day as best we can. Some people will need the
support of others; others will need logistical support at home (shopping, cleaning, care of other
children); others will need to seek information. During this time, it is important to facilitate one's own
wellbeing: good company, enjoyment, rest, good food...
In general, couples who decide to go ahead have little support from physicians, who consider this
attitude as useless suffering. In these cases, the emotional needs of the parents should take precedence,
and as we know, not all people have the same needs. For some parents, the time of pregnancy is
necessary to be able to say goodbye and adapt to the new reality; others will want to assume the
special needs of this new being... We recommend reading the text on the loss of Kai available on the
blog Paideia en Familia.
We have received many stories from couples reflecting the pressure they have received from the
medical team to choose therapeutic abortion in the face of a poor prenatal diagnosis. We wonder if this
position has to do with the fact that if this route is chosen, the intervention is not at the expense of the
physicians who urge it. If the couple decides to continue, these doctors are going to have to follow this
pregnancy and be present at a very hard delivery, with negative consequences already expected. We
see a possible relationship between these issues that reinforce the prescription of therapeutic abortion
but are not based on studies or what is really best for these couples in the long run.

Pregnancy termination
If the couple decides to terminate the pregnancy, the following are some considerations that it would
be advisable to take into account:
- Naming the baby: it will depend on whether or not the sex of the baby is known. Some women
think it is a boy or a girl and name it what they would have liked. Putting a name means making it real,
validating that he or she has been part of the family. The option of not naming the child would also be
valid if the parents so choose.
- How to terminate a pregnancy: parents should be aware of the different ways to terminate a
pregnancy and choose the one that is most appropriate for them. A very important issue that is not
usually taken into consideration, especially in these cases, is that this is not a common loss, because
when the woman comes to the clinic her baby is alive in her womb. If she dies, the delivery takes
place in the private or public hospital where she would have had it anyway. If the baby is alive, the
mother is referred to a center specialized in voluntary termination of pregnancy, most of the time
private. It can be painful for the woman to agree to the termination of pregnancy if she feels or has felt
the movements of the baby in her womb; it is traumatic in itself to know that with her decision she is
going to kill her child, even though she feels fully justified in doing so, since all the mother's cells are
oriented towards life. To avoid possible feelings of deep guilt, it would be advisable a therapeutic
treatment for both partners in order to learn how to manage all these feelings and emotions that will
erupt like an erupting volcano. Some parents have explained that they would have liked to have more
information about the pregnancy termination procedure before going to the hospital/clinic. Some
women have described the day of the termination as the worst day of their lives, complaining of being
alone (without their partner), of not feeling accompanied, of crying and feeling questioned for their
sadness, of being next to teenage girls who terminated their pregnancies for reasons other than their
own... Ideally, the procedure itself should not add more pain: to have information, to be accompanied,
not to see the pain minimized, not to feel judged....
- The birth: it is important to have options, to have real and contrasted information about the pros
and cons of each one of them, and to let the mother and father decide. Some women may receive
general anesthesia, may not be allowed to have a physiological delivery... For the mother, feeling the
baby going through the birth canal may be the only experience of physical contact she will have with
the baby, and it will stay with her forever. The contractions may be more painful, the labor longer...
but a good accompaniment during labor can give very good results. Choosing a cesarean section, in
addition to the loss of experience for the woman, may compromise future deliveries.
- Photographs: one way to make the baby real is through photos. Sometimes, it will be necessary to
wrap it to conceal abnormalities. In some hospitals a photograph of the baby is taken as a matter of
protocol; even if the parents are not at the best time to take it or see it, after a while it will be a good
souvenir.
- The time to say goodbye: it is important that the woman or both members of the couple decide if
they want to say goodbye to the baby, either themselves or other family members. In this regard, it
would be appropriate for both mother and father to do what they consider beneficial for them.
Sometimes, seeing that the malformation was real and not a mistake and that the baby was a baby and
not a monster can be very helpful in the grieving process. A U.S. study has shown that seeing and
cuddling a baby reduces symptoms of anxiety and depression.
- Depending on the type of termination, it is likely that there is no possibility of seeing the baby,
but in such a case the parents can resort to ultrasound scans, a pregnancy test, a diary, planting a tree
or any ritual to help them come to terms with the loss. For many couples, the worst part of the
experience has been the feeling of loneliness, the impossibility of being able to explain what
happened: few people around them knew about the pregnancy, there is a fear of being judged, the pain
is often minimized or they feel that they deserve the bad things they are going through and do not even
deserve comfort because, after all, it was their decision.

Postpartum
Sometimes mothers do not even take time off work to recover from pregnancy, childbirth and/or
termination, perhaps due to a need for denial and to get back to normal as soon as possible.
Professional psychological accompaniment and support can promote emotional well-being for both the
mother and the father, a well-being that in turn will lead to a better physical recovery of the woman.

CHAPTER 7
Voluntary Interruption of Pregnancy (VTP)

From time to time, in dealing with and accompanying unintended gestational losses, the question of
voluntary loss arises. The information on this subject is very controversial, because behind extreme
conclusions there are extreme positions, both for and against. There are very few objective studies,
free of ideological contamination, in this regard.
A large number of women are concerned because, although the law (in Spain) allows abortion, they
end up doing it alone, without adequate accompaniment and even paying for it out of pocket in private
clinics. They recount desolate experiences, fast, cold, lonely and uninformed care. Sometimes, the
professional attitude and the intervention can be more traumatic than the decision itself, from which
we deduce the need for more information and rigorous studies on abortion.
Making the decision whether or not to continue with an ongoing life in the womb is transcendental.
Whether one chooses to continue or to interrupt, the decision will transcend: a child is for life, they
say, and, we add: an abortion, too.
The adjective "voluntary" has been repeatedly put in quotation marks because in a society where
gender equality does not exist, where abuse has not been eradicated and where motherhood is so
unprotected, it is very upsetting. There is a temporary urgency in making the decision, sometimes
accompanied by coercion from the environment. Female fertility is thus approached in a timely,
synchronic manner. Without a holistic approach, this specific pregnancy is focused and solved, but the
subsequent history is not studied diachronically, and we are not referring only to the psychology, but
to the history of fertility and motherhood of each woman who has opted for a VTP.

The duel
A woman who voluntarily decides to stop the gestation of the healthy child she is carrying has specific
motivations that no one has the right to judge. No one makes such a decision happily unless he or she
has thought long and hard about the pros and cons.
The problem is that the legalization of voluntary abortion has led to such a minimization of the loss
that many mothers find themselves in desolation in the face of the mourning that they will necessarily
have to develop. In general, and to avoid the emotional impact, words such as "what you have inside
you are only cells at this moment" are usually said.
If a pregnancy desired and then lost is a taboo that is minimized and ignored as something that "did
not happen", a planned abortion is even more so, because the woman finds no place to express her
pain and grief for a child she may have wanted but could not afford to have. One of the messages you
might receive is, for example, something like, "You should be happy about the laws in this country,
which allow you to own your body and have an abortion if you get pregnant and don't want to have it."
Socially, mourning is denied, and women also deny it, because it seems to be the easiest way out of
such an emotional situation, but denial is not the most appropriate thing to do. Ideally, parents should
be able to grieve for their child and have access to counseling as part of the voluntary termination
process.
Supposedly, voluntary abortion should not provoke any feelings of guilt in the woman and/or her
partner, but rather allow her to feel her emotions, make the transition, say goodbye to the baby's soul
and allow it to leave. A woman who chooses to say goodbye to a child by aborting it makes a great
sacrifice, and these are never gratuitous. Although she may not be aware of it at the time, it would be a
good idea to gain this knowledge in order to be able to live in peace with herself for the rest of her
days.

CHAPTER 8
Loss management

There should be absolute transparency in the medical information that the mother receives when
deciding how to deliver her stillborn baby. It should also be based on scientific evidence, seeking and
proposing the least invasive method that is of greatest benefit to the mother.
When a woman is faced with the hard moment of assuming the loss of a desired pregnancy, she
usually does not know what to do, what is the right way to approach it. You will need a lot of support
to be able to make appropriate choices, and you will also be very vulnerable and manipulable.
In the mind of the expectant mother facing the loss of her baby, a whole set of feelings that complicate
the decision making process are usually mixed.
The inability to understand what happened and the pain of loss are mixed with the deceptive need to
turn the page urgently to mitigate that same pain. Sometimes she is even confused with feelings of
guilt that she cannot manage, overwhelmed by the bewilderment of seeing how her body begins the
path of no return towards the loss of her baby without her being able to do anything to avoid it; unable
to control it. His mind and body radiate frustration and anger.
Many women feel deep fear and mixed feelings at the thought of having their dead baby inside their
body. The deep pain from which they feel they need to emerge is met by a certain resistance to the
arrival of the inevitable moment when they will experience that fatal farewell. In addition to this, the
collective ignorance regarding the handling of abortion, besides ignoring and underestimating this
maelstrom of feelings, has imprinted in the subconscious the idea that it is very dangerous for the
mother "to have her baby inside" and that it is necessary to take it out as soon as possible. Once again,
haste is the order of the day. For the mother, the idea that the baby that is the fruit of her wishes and
desires may also be detrimental to her health can be traumatic. Their fears will be even more
accentuated, which may precipitate inappropriate decisions as a result.
The fact that the baby is already dead at the time of delivery tends to depersonalize the process and not
to value the impact of the interventions exerted on the mother, because the baby can no longer suffer
them. The baby is often considered an object that can and should be acted upon without too much
sentimentality.
As stated, for example, in the WHO definition of fetal death, the baby is a product to be removed by
the physician (called active management). The tendency to resort to active management to remove it is
so frequent that this type of action is implicit and even included in the definition itself: "death prior to
the expulsion or complete removal of a product of conception from its mother, regardless of the
duration of the pregnancy".
Gestational loss is a real shock for parents. The way in which the parents and the professionals interact
and the way in which the abortion is carried out will be key to the subsequent experience of the
parents, not only from an emotional point of view, but also from a physical point of view.
During gestational loss, the same shortcomings that have been demonstrated in childbirth care
continue to occur, except that unlike childbirth, there is a great gap in the development of consensus-
based strategies to promote the implementation of good practices in the case of pregnancy loss.
One of the key aspects to promote is empowerment. The mother needs to receive accurate, complete
and unbiased information. The woman needs to know what she is facing, what options are available,
not only the one suggested by the physician, and she must know the risk versus benefit balance of each
of them. You need to know why the doctor believes that the option he or she suggests is the best one,
and above all, if that option is the one that really suits your needs. Also if it is the method that will be
the least invasive to your physical and emotional health.
In addition, in this decision making process there must be a certain empathy on the part of the
professional to understand the feelings and needs of the mother at such a delicate moment, and with
this, to adapt the final choice and the necessary times.
A physician can help initiate good grief and anticipate situations that may be stressful.
The woman needs to have her feelings validated, as the social silence that is generated around the loss
makes her feel that no one is able to see how bad she feels internally.
Professionals therefore play a crucial role in how the experience of loss is defined. They have a great
power to reduce the impact of this and the associated trauma, and with it, the possible psychological
sequelae of the same.
Women cannot be treated (or feel) as a mere womb or container for babies. They are individual beings
who require individualized and personal treatment and action, and we must demand that this be so.
The psychological pain of the loss may be too much knowing that the dead baby is still with her.
Knowing both sides of the coin, the advantages and risks of these two management options, will help
empower the woman, providing her with greater internal resources to decide the option that best suits
her physical and emotional needs and that will result in a greater benefit to her health.

Active management
Active management consists of resorting to some type of medical intervention, either by drug
administration or surgical technique, to induce the mother to expel the baby. It is an artificial process
that requires specialized medical supervision and action, since it involves the manipulation and
alteration of the body's natural physiology and can generate complications that must be closely
controlled. From less interventionist to more interventionist, the methods can be classified as follows:
- Pharmacological abortion.
- Surgical abortion: by aspiration curettage or curettage. It would also include abortion by cesarean
section, although this case is only indicated in advanced gestations with fetal presentations and/or
situations incompatible with vaginal delivery.
The choice of one or the other depends not only on maternal desires but also on other factors, such as
gestational age, if the abortion has already begun but has only partially elapsed (incomplete abortion)
and the process does not progress on its own, or if signs of infection or excessive bleeding appear.
Accordingly, some methodologies will prevail over others because they are the least complicated and
have the greatest benefits for maternal health in their particular circumstances. But when there are no
circumstances that demonstrate, based on scientific studies, a preferential need for one technique over
another, the mother should choose the method that best suits her own needs, cultural background and
desires. And physicians should put on the same level the different options that are safe for their
individual circumstance without imposing their personal preferences on top of it.
What happens when the physiology is altered: in a normal pregnancy, for it to progress normally, it is
necessary to maintain a specific level of hormones, mainly estrogen and progesterone. Estrogens are
responsible for making the uterus grow, while progesterone ensures that the uterus does not contract
during this growth and that the cervix remains closed. When the concentration of progesterone
decreases (as occurs at the end of pregnancy), the natural production of prostaglandins is activated,
which in turn activates the contractility of the uterus increasing the endogenous production of
oxytocin, favoring the dilatation of the cervix and the subsequent exit of the baby. Pharmacological
abortion can therefore be achieved when these natural mechanisms are artificially altered and the
pathways that stimulate labor are activated. (i) drugs analogous to natural prostaglandins or (ii)
oxytocin that activates uterine contractions (although it is relatively ineffective if the pregnancy is not
full term or if labor has not started spontaneously, requiring that some form of prostaglandins have
been administered beforehand) or (iii) antiprogestagens that block progesterone receptors and decrease
their inhibitory action.(iii) antiprogestagens that block progesterone receptors and decrease their
inhibitory action on uterine contraction, activating the consequent synthesis of natural prostaglandins.
Another way to induce labor pharmacologically is to inject hypertonic saline solutions that induce an
osmotic change resulting in necrosis of the amnion, the chorion and the fetal surface of the placenta
causing the release of prostaglandins and causing the onset of uterine contractions a few hours after
the injection. At present, this option is not usually chosen in isolation but as a complement to others; it
is used, above all, in voluntary terminations of pregnancy that take place above 14 weeks of gestation
in order to ensure the death of the baby before proceeding to the abortion itself, since the baby ingests
the solution and dies shortly after the poisoning. Hydrophilic dilators can also be introduced into the
cervical os. These are rods, usually made of polymer, which absorb cervical fluid by expanding and
stimulating the production of prostaglandins. The same effect can be achieved by introducing
mechanical dilators of different sizes, such as Hegar stems, which are metal cylinders in increasing
order of diameter that gradually open the cervical os. It is an aggressive procedure, particularly in the
case of mechanical dilators that can cause tears in the cervix, which can be avoided if the cervix is
previously softened or dilated. This can easily be done by resorting to the use of prostaglandins hours
before the procedure.
Surgical treatment of abortion is based on the techniques of aspiration curettage (vacuum aspiration)
or curettage with curette (simple curettage). Both are invasive techniques that must be performed in
the operating room and under some type of anesthesia. Years ago they were used as the first option in
first trimester gestational losses because of the feeling that they did not involve major risks, but it is
known that surgical management seems to involve a higher risk of infection and adverse effects on
future fertility, in addition to a higher overall cost. Therefore, nowadays, especially in early gestations,
it is also considered safe to use labor-inducing drugs as a first option. Increasingly, this type of
technique is left only for cases in which complete expulsion of the remains is not achieved, or in any
case, depending on the mother's wishes and provided that there are no other circumstances that
indicate that the surgical option is more appropriate. If the mother wishes to ensure that the abortion
proceeds quickly and with a high probability of being complete on the spot, then surgical abortion is
the method of choice.
Curettage by aspiration consists of the extraction of the embryo or fetus by means of a cannula
connected to a vacuum pump (electric aspiration) or to a syringe through which suction is performed
(manual aspiration), both techniques being equally safe. The cannula is introduced through the
cervical orifice, and then aspirated by means of a rotational movement through the cannula for
evacuation. Depending on the gestational week, a greater or lesser degree of dilatation of the cervix
may be required prior to aspiration. Below nine weeks gestation, a maximum of an 8mm cannula is
used, and many women do not even require dilation. If necessary, hydrophilic or mechanical dilators
are used. For this reason, in early gestations this method is called aspiration only, and in more
advanced gestations that require prior dilatation, it is called dilatation and evacuation. Depending on
the degree of dilatation required and the mother's wishes, less or more analgesia may be required.
Complete evacuation of the baby and placenta should be verified by examination of extracted
contents. This is essential to ensure that there are no remains, that they correspond to a baby of the
expected gestational age (to rule out molar pregnancy) and that there is no ectopic pregnancy, in which
case the uterus will be empty, and the abortion will have to be performed in another way. Ideally,
these cases should be previously diagnosed by ultrasound.
Simple curettage with curette, also called dilatation and curettage in the case of advanced gestations, is
a methodology that involves more risks than vacuum aspiration. Compared to the latter, it has a lower
rate of complete abortions and higher rates of complications such as more blood loss, longer hospital
stay, higher risk of infection, uterine perforation or uterine adhesions, as well as a greater need for
anesthetics. On average, it is estimated that curettage with curettage implies a 2, 3 times higher risk of
presenting complications of any type compared to aspiration.
Thus, with the option of choosing alternative methods, curettage should be relegated to oblivion.
Specific risks associated with curettage:
Because of the discomfort involved, it must be performed in the operating room and usually involves a
higher degree of anesthesia than vacuum aspiration. It is usually performed under general anesthesia
or sedation (in some cases it can be performed under regional anesthesia). The methodology involves
separation of the vaginal walls with a flap and subsequent clamping of the cervix by traction to avoid
perforation. If the neck is closed, it is instrumentally dilated using hydrophilic or mechanical dilators.
This dilatation is greatly facilitated if the cervix is previously softened by means of prostaglandins, or
if labor has begun naturally, in which case it would already be partially dilated. Once the cervix is
dilated, the curette is introduced, which is like a sharp blade that will allow the walls of the uterus to
be scraped to detach the placenta and the baby from them. Always choose the largest size curette that
fits through the cervical os and insert it into the uterine fundus. Then, by means of a return movement
towards the cervix, the four walls are explored until the entire uterine cavity is evacuated. The critical
point of curettage, and what makes it potentially dangerous, is that although the process can be done
with ultrasound monitoring, many professionals do not do it following this method and scrape blindly.
Another difficulty is to know when to stop scraping, because excessive scraping can lead to the
removal of internal uterine layers, leaving the uterus heavily damaged. Intrauterine trauma resulting
from curettage is a common etiologic agent in the development of intrauterine adhesions that can lead
to local synechiae. Therefore, the origin of synechiae as a consequence of curettage is nothing other
than a "traumatic ablation" of the endometrium; this is due to the fact that during the procedure, if the
procedure is too vigorous, it causes the basal layer of the endometrium to be exposed to the
myometrium. Fibroblast activity and collagen formation are promoted before the normal endometrial
regeneration process takes place, which is then hindered; this favors the adhesion of adjacent walls of
the uterine cavity. The different regions of the uterus are fused by "cables" of connective tissue,
sometimes even creating authentic "spider webs" inside the uterus, which can generate not only
numerous discomforts and gynecological problems, but can also be the cause of secondary infertility.
Symptoms vary according to the extent of the lesion: menstrual disturbances, chronic pelvic pain,
recurrent miscarriages, placental insertion disturbances and infertility; and in extreme cases it can lead
to Asherman's syndrome and be associated with the development of endometriosis (endometrial tissue
growing outside the uterus invading other adjacent organs and structures).
It has been found that about 60% of the synechiae or uterine adhesions associated with Asherman's
syndrome are the result of curettage. Synechiae can also generate the "amniotic savannah", which can
be confused with the casuistry of the "amniotic bridle". The term "amniotic sheet" was used to
describe the particular ultrasound image in which a cross-sectional synechia is seen encompassed by
the amnion and corin, similar to the relationship of the peritoneum and mesentery to the bowel. The
"amniotic bridle", which causes a multitude of fetal malformations, has an origin unrelated to
synechia. The two events should not be confused, although unfortunately their similarity may result in
the presence of synechia leading to an erroneous prenatal diagnosis of "amniotic bridle". Synechiae are
generally uncomplicated during gestation, although there is evidence to suggest that large uterine
synechiae may be the cause of presentation dystocia and low birth weight babies. On the contrary,
amniotic bands can cause fetal malformations, often incompatible with life, and can lead to voluntary
termination of pregnancy. The key is to use color Doppler ultrasound to differentiate it, with which
blood circulation can be seen at the level of the synechia, which is not seen in amniotic bands.
Synechiae can also be confused during a healthy gestation with the presence of other problems such as
a suction hemorrhage, giving the impression of the placenta, an image that can simulate this type of
hemorrhage.
Post-graduate procedures have been proposed to help reduce the likelihood of synechiae formation,
such as the implantation of an endometrial cavity device (IUD) into the uterus to separate the uterine
walls to the greatest extent possible during endometrial regeneration. Cyclic therapy with conjugated
estrogens and progesterone at high doses is another resource that actively stimulates endometrial
proliferation reducing the incidence of intrauterine synechiae. But the truth is that, since there is an
alternative method, such as vacuum aspiration, which lacks these risks and is, in general, much safer,
this should be sufficient reason to invite professionals to refrain from using this technique. Finally, it is
also worth mentioning an increased risk of uterine perforation with curettage; although its incidence is
low and is reduced when the professional is highly experienced, it is still an important risk. Treatment
for perforation varies depending on the symptoms. If perforation is suspected, curettage should be
interrupted, maintaining a conservative approach unless there is peritoneal irritation due to visceral
injury, intense bleeding or extensive hematoma, in which case urgent abdominal surgery should be
performed. Because of all the risks, we assume that curettage should be exceptional. For this reason,
we call this method illegrade (unnecessary curettage), since we find many cases in which this
technique is used without being necessary or appropriate, when the abortion could have been managed
in a much less invasive way (pharmacological or vacuum aspiration) or expectantly.
The crux of the option to choose is to select the appropriate management according to the gestational
age and also taking into account the side effects of the same for each case and, of course, taking into
account the maternal wishes. It is also necessary to take into account whether the miscarriage was
spontaneous or the result of an abortion, either because of problems that prevent the normal
development of the baby or for other reasons. These factors may tip the balance toward one method or
the other because they may require additional procedures during the abortion process. However, we
will focus mainly on the methods mostly used in the first case, in which the abortion was spontaneous,
although in reality, most aspects of the procedures are valid for any type of abortion.
Pharmacological management vs. surgical management: up to 9 weeks of gestation, pharmacological
management is a very effective method in most abortions, although surgical management is also used,
especially when the aim is to shorten the process and guarantee the success of the abortion in the short
term. In this case, most often, in fact, both options are combined using drugs (prostaglandins) to soften
the cervix and facilitate subsequent aspiration. Pre-dilation of the cervix also reduces the incidence of
other complications such as damage to the uterus and/or cervix, hemorrhage and retained debris. The
scientific evidence suggests that both methods are equally safe if there are no other indications of
problems that would suggest that one type of action should prevail over the other. Both options have
the same degree of performance should prevail over the other. Both options present the same degree of
complications and generate similar rates of complete abortions (although slightly higher in the case of
vacuum aspiration).
However, this method of acting invites us to ask ourselves to what extent the end in itself of using the
surgical method because of its greater speed justifies it being the first option, since it is still a very
invasive method. If prostaglandins are considered for use to soften the cervix prior to surgery, the
woman will be given the same medication as if only the pharmacological option were chosen, but she
will not be offered the alternative of waiting to see if she will expel the baby on her own, in which
case the surgical procedure would be spared. Thus, the woman will suffer the effect of the sum of the
two options in exchange for greater speed. This is despite the fact that this speed is not always ideal in
all cases and depends very much on the emotional state and the mother's wishes.
Provided that there are no signs of complications and unless the mother expressly wishes, once the
woman has been given the drugs, it should be possible to allow time to pass and check their
effectiveness, so that she only undergoes surgery if strictly necessary.
It is important to keep in mind that not all pharmacological options work the same and do not have the
same risks. For example, prostaglandins alone (misoprostol) are not sufficiently effective (between 3
and 7% of women experience incomplete abortions and will need curettage). In addition, several
successive doses are required, and bleeding can last for many days. If bleeding is very profuse,
emergency curettage for homeostatic purposes may be necessary. Something similar occurs with
antiprogestagens (mifepristone), which have an even lower effectiveness (between 60 and 70%).
However, the process of expulsion of the remains is more effective if both drugs are combined; in such
a case, it usually leads to a faster abortion, with fewer side effects and a higher rate of complete
abortions, avoiding the need for surgical management. An interesting option is the combined use of
mifepristone and misoprostol because of the advantage that misoprostol can be administered orally
instead of vaginally (which some women find uncomfortable or unpleasant). Several studies have
shown in first and second trimester gestations that administration of misoprostol 24-48 hours after
mifepristone allows complete abortion in a high percentage of cases, and if an additional dose of
misoprostol is administered within hours after the first dose, the success rate may be even higher. This
method could even be compatible with managing the abortion at home rather than in the hospital.
From the 14th week of gestation until the end of pregnancy, due to the size of the baby, the use of
vacuum aspiration as the first method is complicated, since it is necessary to dilate the cervix well and
fragment the baby before extracting it. This can be especially traumatic for the parents, particularly
when the baby is wanted, and can be an impediment to internalization and grieving, as the sight of the
baby after such a procedure would be very violent; they will not be able to say goodbye to the baby for
this reason. Because of this, and the reasons previously mentioned for first trimester losses, the
pharmacological option is more suitable. In general, the uterus at this gestational age is more sensitive
to pharmacological stimulation, and with proper treatment it is effective and relatively easy for labor
and expulsion of the baby to be accomplished by this means. Among the different pharmacological
options, mifepristone, administered 24-48 hours before inducing abortion with prostaglandins, also
tends to become the ideal method. The combination of both drugs reduces the active labor phase time
from 14-36h of isolated prostaglandins (depending on the prostaglandin and the method of
application) to only 4.5 - 8.5h. In addition, it reduces the dose of prostaglandins needed, thus also
reducing pain, digestive discomfort caused by prostaglandins alone, and cervical tear rates. On the
other hand, it has a comparatively higher rate of complete abortions (66% vs. 50%). Hydrophilic
dilators can be used as an alternative to prostaglandins, and oxytocin can be applied as a booster to
ensure a higher labor success rate. If dilatation is good and labor starts normally, the mother will have
a normal delivery, and it would only be necessary to verify by ultrasound and visual inspection that
there are no remains that would require a subsequent curettage by vacuum aspiration.
The problem with the choice of pharmacological management appears, however, in losses between 9
and 14 weeks of gestation. There is a prevailing belief that pharmacological induction, although a
good option, would not generate complete abortions in such a high percentage as when performed in
the first trimester up to week 9 or in the second trimester from week 14 onwards (although in these
cases a higher and repeated dose of drugs is required). This could be because it may be more difficult
to achieve the necessary dilatation of the cervix, and some debris, due to the larger size of the baby,
could be retained. Vacuum aspiration, on the other hand, would offer a higher rate of complete
abortions. On this basis, most obstetricians consider it better to opt for vacuum aspiration, thus
subjecting to this process women who could have expelled the fetus on their own without the need for
this procedure.
Although it is true that we do not have too many studies that analyze this aspect at this gestational age,
this change in criterion is not, however, supported by the latest scientific evidence. For example, in
2006, a large randomized study was carried out in pregnancies up to 13 weeks showing that
pharmacological induction is safe, with no major disadvantages compared to surgical management. A
2007 review by Cochran also shows that pharmacological induction in gestations up to 24 weeks is
safe. Therefore, we question this ambivalent criterion according to which pharmacological
management is only appropriate up to week 9 and after week 14, but not at intermediate gestational
ages. For some strange reason, which is certainly not based on scientific evidence, it seems as if the
work that the mother's body does outside is more defective and incapable just in that interval than in
the others. This reasoning seems implausible. The criterion of the size of the baby does not seem to be
sufficiently substantiated either, since from week 14, when the baby is older, pharmacological
management continues to work (although in different doses).
Perhaps the difference in criteria is due precisely to this: the exact dose in these cases is not
sufficiently studied and it is more difficult to find the adequate dose to be effective without adding
more side effects, since it is difficult to find a consensus, and there is a great disparity of regimens and
doses of administration. In general, what does seem to be demonstrated is that the use of misoprostol
vaginally would be the most effective option, rather than orally. Therefore, it is a possible and
recommendable option, although it would nevertheless be necessary to have more extensive studies
that analyze this intermediate period of gestation between the first and second trimester to investigate
the suitability of the drug to be used and the most appropriate dose of pharmacological management
with respect to surgical management, and thus favor a change in the current paradigm that has
obstetricians so anchored in surgical management during this period of gestation.This would favor a
change in the current paradigm in which obstetricians are so anchored in surgical management during
this gestational period. Aspiration at this gestational age is comfortable and easy to perform, since it
does not require excessive dilatation and the baby does not need to be fragmented, which is one of the
reasons why it is so frequently avoided after the 14th week.
The fact that from the 14th week of gestation onwards pharmacological management is the first option
has been driven by the size of the baby, which makes it more laborious. The inertia of aspirating
between 9 and 14 weeks seems, therefore, to be linked to it being a comfortable choice rather than
because pharmacological management does not work.
In order to choose between the different methods, it is necessary to be aware of the associated risks.
Both labor-inducing drugs and vacuum aspiration have significant side effects, so this treatment
should never be performed without strong medical supervision, and the mother should receive a clear
and effective explanation before making a conscious decision. Many prostaglandin analogues can
cause severe digestive discomfort, such as diarrhea and/or vomiting.
They can also cause cervical tears in 1% of cases, although this percentage drops to 0.1% if combined
with anti-protegens.
Oxytocin should not be used in early gestations because of its relative ineffectiveness. It may be
necessary in pregnancies beyond the 3rd trimester as a means of strengthening and increasing uterine
contractions provided that medications have been previously administered to soften the cervix and
activate uterine contractility. It has the adverse effect of being an important anti-diuretic, because it
could cause water overload if the symptoms are not well recognized or it is not properly administered,
and there have been cases of brain damage or even death due to this cause. In high doses, oxytocin can
cause uterine hypertonia and uterine rupture, so special care must be taken in its use, especially in
women with previous cesarean section. The same care should be taken with prostaglandins, which can
also be a risk agent for uterine rupture in patients with previous cesarean section. Apart from all this,
the administration of any of these drugs is usually accompanied by severe pain and abundant blood
loss. It is crucial to monitor the level of bleeding, the presence of fever as an indication of infection
and to perform frequent ultrasounds to verify the complete expulsion of the baby and placenta.
When vacuum aspiration is chosen, to these effects of the drugs used to dilate the cervix must be
added those specifically associated with the aspirate, which are mainly those derived from anesthesia.
This typically includes nonsteroidal anti-inflammatory drugs and paracervical blocks with 10-20cc of
1% lidocaine. To prolong the anesthetic effect, agents such as ropivacaine and fentanyl can be
included in the anesthetic cocktail, or oral or intravenous sedation or anxiolytics can be administered,
although these have not shown a significant effect on pain reduction. After the process, a uterotonic
agent such as methylergonovine is usually administered to promote uterine contraction and reduce
vaginal bleeding. If the mother is also Rh negative, she should be vaccinated with Anti-D
Hyperimmune Gamma Globulin.
Finally, there is a low but existing risk of uterine perforation that cannot be neglected, although the use
of ultrasound methods during the process can reduce this risk considerably.

Expectant management
Few women know that the abortion process, whatever the gestational age, can be carried out
differently. What is known as "expectant management" involves allowing the body to do for itself,
letting the body recognize the death of the baby and deliver it; its safety is scientifically supported.
The only requirement is to give the body the necessary time to do so, as it can take from several days
to several weeks.
Many doctors who are outdated in their protocols consider this option to be nothing less than reckless,
or only recommend it in very early gestations or in those where an imminent miscarriage is confirmed,
but advise against it for pregnancies with a gestational age of more than 9-12 weeks. Thus, many of
these professionals omit this option from the available alternatives, forcing the woman to choose
active management, whether pharmacological, by vacuum aspiration or curettage.
Sometimes, even if the woman asks for it, she is often frightened by a myriad of risks that would arise
in case she chooses the option contrary to active management, conditioning her final decision. It
should not be forgotten that, for a professional, to be attentive to a pregnant woman for weeks,
performing ultrasound scans and giving them their time and dedication has an assistance and personal
cost that not everyone is willing to assume. In the face of this, active management allows the
professional to solve the problem more quickly. This is similar to what has happened with medicalized
childbirth, which went from being an exceptional or infrequent option in its beginnings, to being the
option of choice. All deliveries, including those of low risk, have been actively treated, relegating
low/no intervention natural childbirth, which should be the majority of cases, to a true exception,
without this change in care being supported by scientific evidence or resulting in greater benefits for
maternal and fetal health.
It is enough to take a look at the scientific articles on the management of gestational loss to see the
indisputable change towards the medicalization of abortion in the same way that childbirth began to be
medicalized. As in normal childbirth, this change is not adequately supported by scientific evidence,
and responds to other reasons, such as greater comfort from the point of view of care and the
overvaluation of medical intervention, becoming a routine and insufficiently questioned type of action.
So, it is worth asking ourselves: is expectant management really dangerous, and active management
safer? To what extent are these complications that obstetricians always mention real and to what
extent are they incompatible with the possibility of expectant management? Are we talking about
safety for the woman or comfort for the gynecologist?
The main problems with E management are: the appearance of cogulopathies and infections as a
consequence of incomplete abortion. With respect to coagulopathies, they are frequent when four
weeks after fetal death are exceeded. It is estimated that they occur in 25% of gestations with E
management above 4 weeks, but in spite of this, they usually do not involve serious sequelae.
However, to prevent this potential complication it may be useful to perform blood tests from time to
time (blood fibrinogen levels below 100mg/dl). are usually indicative of coagulopathy).
With respect to infection and the presence of incomplete abortions, it would be sufficient to monitor
for the appearance of fever, pain and/or excessive bleeding and to perform frequent ultrasound scans
to evaluate that there are no retained remains, in which case surgical management would be used.
However, it is also not advisable to exacerbate the surveillance process with ultrasound scans, as this
can lead to impatience and may result in the patient finally being operated on, rather than waiting a
little longer.
At this point it is important not to confuse expectant management with abandoning the woman to her
fate, or doing nothing. Always keep a watchful eye. From the moment the case is diagnosed, each
situation must be assessed, risks must be weighed and, if possible and if the mother so decides, the
mother must wait with vigilance. It should also be noted that vaginal ultrasound scans have a very high
value in the follow-up of expectant management abortion, since it has the capacity to diagnose the
presence of adherent fetal tissue that has not been expelled very accurately, so that active management
could be left for the case that it is strictly necessary. With these precautions, E handling is a safe
option.

Expectant vs. active management

The following is a summary of the most relevant studies comparing management E with management
A, where the safety of management E is evident.
First, it is important to keep in mind that when analyzing the scientific literature for such a
comparison, the reader should be aware that the assessment of the success/risk of a method in question
is usually measured by the percentage of complete vs. incomplete abortions requiring surgical
management. Although a priori this parameter may seem to be a very objective criterion, in reality this
parameter will necessarily depend on the time the body is allowed to do its work in E management.
Except for specific studies, in general, almost none usually analyze the success of E management
beyond one, or at most 2 weeks, as most obstetricians rely on the 2-week rule. This rule considers E
management to be safe at least for that period of time, and based on it obstetricians are reluctant to
wait longer because they are not confident of having a higher success rate even if given more time and
probably because of the fear of coagulopathy. Therefore, it is difficult to know whether an even higher
rate than that reflected in these studies could be achieved with a little more time (as long as there are
no clinical indications to the contrary), especially when recent studies show that it would be safe to
wait between 6 and 8 weeks. Of the vast majority of women who followed the E management and
gave their testimony at the Overcoming Abortion Forum, the process was initiated between 4 and 8
weeks after the arrest of the heartbeat, most of them around 6 weeks, and they did not present any
complications.
On the other hand, basing the choice on this data alone is dangerous, because in order to achieve
complete success, the body is being medicalized and altered by performing even a surgical process. A
very similar analogy would be the cesarean vs. vaginal delivery dichotomy. Cesarean section, as a
surgical method, allows to remove the baby quickly, which would be 100% effective in the short term,
and on certain occasions when there are complications, it would be the ideal option. But the fact that
allowing a woman to have a vaginal birth may take longer to deliver her baby, or even sometimes
require external intervention because it does not go well the first time in certain cases, does not justify
that the ideal option for childbirth is a cesarean section. Therefore, in addition to the success of
complete abortions in the short term, other indicators such as bleeding, infection rate and the impact
on the woman's emotional health must be reviewed.
During the 1st trimester and up to 14 weeks or so, scientific articles comparing E management to
medicalized management demonstrate that E is as safe or safer than the active option.
We must keep in mind that E does not only mean not to medicate, but it implies a whole set of
attitudes dedicated to valuing the capacity of the mother's body to deliver the baby by herself, and at
the same time it requires empowerment on the part of the mother and those around her to do so. So
deceiving her with a placebo can hardly achieve this goal.
The side effects derived from each option in the different studies, such as diarrhea or vomiting, were
significantly higher in pharmacological management and there only appeared to be a slightly higher
tendency to greater bleeding with E management.
After 14 weeks, physicians recommend inducing labor medically and/or performing surgical
management because they consider E management to be dangerous. There are no clear or scientific
explanations for this change in criterion because there are no concrete studies that analyze it and
demonstrate that it is a harmful option. This attitude seems to respond to an inertia to overestimate the
efficiency of active management.
It should be taken into account when assessing E management is that there are cases of prenatal
misdiagnosis that can lead to miscarriage of a live, healthy baby. Although it may seem anecdotal,
there are cases of fetal death diagnoses in babies who were alive due to failures of diagnostic
methodology and/or skill on the part of the diagnostician. This type of error, especially in early
gestations, may also be due to the methodology used to date the gestational age; if this is based on the
date of the last menstrual period, it may lead to errors that lead to expect a certain developmental size
that in reality may not be present, not because the baby is compromised but because it actually has a
lower gestational age and is perfectly normal. Generally, the presence of one or more of these events is
considered indicative of miscarriage:
- Absence of fetal heartbeat if the embryo is larger than 5mm or absence of fetal heartbeat in an
embryo that previously had one.
- Gestational sac greater than 8mm without egg (hollow egg).
- Gestational sac greater than 16mm without embryo (anembryonic pregnancy).
- Reduced levels of hormones such as chorionic gonadotropin (hGC) or progesterone, although
there have been certain cases in which low levels of hGC can occur while the baby is viable, such as in
cases of evanescent twin syndrome or in heterotopic pregnancy.
- After the 1st trimester, other significant signs of fetal compromise may be: absence of fetal
movements, uterine growth height insufficient for the expected gestational age, and appearance of
ultrasound signs such as overlapping of cranial bones (Spalding's sign), hyperflexion of the spine or
presence of gas in the great vessels. However, many of these evidences are not easy to determine in
fetuses younger than 28 weeks.
The diagnosis of spontaneous abortion must be based on the observation of a series of data that
together and inescapably indicate fetal death. The absence of a heartbeat is not a 100% reliable
indicator and therefore should not be an indicator in itself taken in isolation, especially if the mother is
obese or polyhydramnios is present. Therefore, in order to avoid diagnostic errors, it is important that
the diagnosis be based on the verification of several parameters, and not just one.
Having little time to re-confirm the news with a 2nd opinion a few days later before making the
decision to choose A management.
When a professional proposes to induce the abortion with management A immediately after notifying
the parents of the news, or without allowing a reasonable amount of time to elapse, he or she may be
unwittingly facilitating this type of situation. Furthermore, from an emotional point of view and in the
face of post-abortion trauma, it should be kept in mind that the moment after confirmation of the
baby's death is not an absolutely appropriate time to make any kind of decision concerning the type of
management of the abortion. For many parents, the shock of the news is so intense that they are not
even able to understand or assimilate any other information that the physician tries to provide at that
moment, as reflected in the study by Adolfsson et al. Hence the importance of professionals being able
to recognize this and give parents the necessary time before they have to decide which method is the
most appropriate, especially when it has been amply demonstrated that there is no reason to act in
haste. Otherwise, their right to make a free and informed decision would be violated.
The dilemma of choice may come more from an emotional point of view, which is often a
fundamentally personal aspect and difficult to predict. It is necessary to have a broad vision when
making recommendations or assessments in this sense, although from a very reductionist perspective it
could be said that there are two main groups of women: those for whom waiting can be a blessing and
those for whom waiting times, and all that this type of management implies, are agony or torture.
For example, some women find it very hard to face the moment when they have to see their baby,
especially when the loss is early and the baby does not yet have a clear human appearance. For them,
the idea of seeing a poorly developed embryo or fetus may be too impressive and they believe that
they will not be able to cope with it. Nowadays, this impact should be less, since access to ultrasounds,
documentaries and images that show the development of the baby from the beginning of its conception
gives us an image of what the baby we are going to find will be like. Even so, this fear does not only
arise from the fact of seeing their baby, but also from the fear of facing the process alone, of not
knowing what to do or how they will feel when it happens. This fear is significantly reduced when the
process is experienced as a couple or with a partner or doula who provides the necessary support and
confidence.
Sometimes, the imminence of abortion leads some women who thought they could not do it to find
themselves in this situation and have no choice but to go through it. To their surprise, many were
stronger than they thought and were relieved to be able to take advantage of the moment to do the 1st
ritual of their mourning and also for having been lucky enough to see their baby, to hold him, to see
that what they were afraid to see is their baby, their treasure, their dream... and to say goodbye.
We must not lose sight of the fact that for management A, especially if it occurs very soon after the
news of the loss, as could be the case with surgical management, it can lead the woman to go too
quickly from having her child inside her to suddenly not having it at all, without being able to process
it adequately.This increases the feeling of emptiness and loss of control over her body, which
generally begins when the woman detects the first symptoms of the miscarriage. The rapidity of the
process increases these feelings due to the sudden absence of their baby, who, in a very short time
since they received the news, goes from being inside to not being inside.
Other mothers who have gone through a previous loss or have complementary information that makes
them feel confident with E management may be confident and empowered enough to deliberately
choose E management.
Sometimes, being aware of the reluctance of professionals to this type of option can lead them to opt
for it regardless of their physician's opinion. Some even opt for it without going to the medical
services before the first signs of abortion and without even waiting to hear their opinion. In these
cases, when the loss has taken place in this way and they come to them afterwards to verify if the
process has gone well, it can also be very stressful for them to receive disrespectful and/or unfounded
comments criticizing their decision. If the woman is informed and feels confident with her decisions,
what may be a reckless attitude to her physician should be seen as empowering to her experience. The
existence of such cases should be considered as part of the variety of experiences that can arise and
cover the range of women for whom management A is not their option, and who feel prepared and
confident in their bodies to simply wait and let go, waiting for the loss to occur naturally and
physiologically.
Physicians should take the opportunity to learn about these cases and not just those related to active
management options, to learn and know that the same process can be done differently safely, rather
than judging them.
Within this varied emotional component, the similarity of E management to a natural, non-
interventional birth should be emphasized, where the non alteration of physiological hormones is an
added value that provides a high that empowers the woman. It can be a vital agent in mitigating the
hardship and trauma of loss. It can even facilitate a bond with her baby who, although he will no
longer be with her, becomes something real, part of her, someone she can even say goodbye to, touch,
hold... and not just something to be extracted and disposed of. This non-alteration of the process is
usually accompanied, as in many natural births, by a strong dose of endorphins and an increase in the
mother's confidence in her own body. Instead of feeling betrayed that their body has put a stop to their
baby's development, they can look at it from the point of view that their baby could not progress and
that same body has been capable enough to deliver it without problems. It can be an empowering agent
for future pregnancies and deliveries, and these benefits should be explained so that the woman can
weigh them at the time of decision making.

The enemies of expectant management

What needs to be considered when a mother chooses to have a loss following expectant management?
Most of the aspects that hinder the good development of a delivery are the same that can hinder the
good development of a physiological loss. According to Consuelo Ruiz Velez-Frias, the 4 enemies are:
ignorance, fear, pain and impatience.

Ignorance: it is a major difficulty not to know the physiological process of an abortion, its phases.
Not knowing what to expect, what is normal and what are the warning signs. Treating miscarriage as a
disease that requires intervention, medication, anesthesia, surgery, instrumentalization... Allowing the
unfounded idea to spread that if a miscarriage is not curetted, the woman will bleed to death and die
without remedy. All of these are prejudices, conjectures not based on scientific evidence that
undermine, once again, a woman's confidence in her body, the vision of her body as something
defective, that does not work well.
In general, ignorance implies leaving the process passively in the hands of others, leaving the body at
the mercy of unnecessary invasive interventions that physiology would carry out without so many
added risks. Others decide how, when and where to intervene, without being made aware of the
possibility of expectant management with unnecessary urgency, since most abortions are not medical
emergencies, and the mother can be given time to explain the alternatives and to participate in making
decisions about her sexual and reproductive health in a conscientious and adult manner.
Ignorance also means not having complete information about what active management means: how it
is performed, the risks it may entail and the complications that may occur during the intervention and
afterwards.
In this context of ignorance we could also include the perception that many women may have of
expectant management as if it were a lack of medical attention, a saving of resources at their expense,
a feeling of neglect in the care of their early loss. This invasive procedure has been used for so long, as
a matter of routine, that there is a popular belief that without curettage the woman will bleed to death,
or that it is dangerous to have something dead in the uterus, but there is no perceived risk involved.

Fear: hinders expectant management, and is a consequence of the ignorance described in the previous
section. Fear of the unknown, of the physiological process, of abortion being a threatening event for
our life, or for our reproductive life and not being able to have more children... Fear of dying, of
bleeding to death, of catching infections... Fear is a very powerful feeling, which clouds reason and
wisdom, the innate certainties. Fear can be physically and mentally upsetting. The women often say
that because of the fear and sadness they felt (a fatal combination), they let it happen, trusting that
those who cared for them would act in the best way possible. Knowing the source of the fear and
addressing it with a good accompaniment would be a good way to deal with it.
Respectful professional accompaniment in the management of expectant abortion would also help.
Today, too many women who choose this path are abandoned by professionals to their fate because
they have not obeyed and have not followed the only career path indicated: active management. And
they spend the non-medicalized physiological loss alone, in their homes, with professionals looking
the other way, threatening them that their behavior entails a risk of death, labeling this decision as
foolish.
Pain: knowing why a miscarriage hurts, what its phases are, knowing what to expect and knowing
what means are available to defend oneself from this pain without causing harm or undesirable
consequences for the woman would help to understand it and, therefore, be able to cope with it much
better. Filled with emotional pain from the loss, too often without adequate support, women feel a lot
of physical pain. Others do not. As in childbirth, not all women experience contractions and the phases
of labor in the same way. But the experience of a physiological abortion is a work that helps to say
goodbye, to begin the path of mourning. It is important to note that the natural hormonal cocktail that
is set in motion implies an important release of endorphins, important pain palliative agents that make
the breasts feel a euphoria, a power that helps them to cope with the loss and to reconcile with their
body. Michel Odent explains it very clearly (personal communication: "the hormonal cocktail that is
set in motion in a respected loss is an antidepressant in itself, the best".
Abortion is surrounded by taboos that have prevented women from passing on this wisdom of
physiological loss from generation to generation. Today, in the supposedly era of "open and taboo-free
sexuality", abortions continue to be hushed up and treated in the operating room as something to be
urgently removed, like an annoying appendix. And, in fact, the remains of that baby are treated in this
way: as surgical offal, which says a lot about the sensitivity and understanding of this subject by our
culture. Since abortion is considered a disease that requires surgical intervention with general
anesthesia, its logical consequence is to think that it is a process so painful that it cannot be endured
alive; pain that is difficult to bear without a good accompaniment, because it must be added to the pain
of loss that diminishes the feeling of strength to face it.
The disadvantage of dispensing with the wisdom of the woman's body to expel that pregnancy which,
for whatever reason, is not progressing, is that some women live without living it, with an unnatural
rapidity without the psyche internalizing it or recording it. No time to register it.

Impatience: Abortion, as a general rule, is not a medical emergency. In fact, waiting for the body to
start up, i.e. 6 to 8 weeks after the arrest of the heartbeat, would avoid many curettages and aspirates.
Many more if we take into account that most of the interventions are performed while the woman is in
the middle of the bleeding process. It is as if a woman in dynamic labor, without any complications,
were to have a cesarean section. Sometimes we might even wonder if the curettage is done so quickly
to ensure the intervention, because if we waited a little longer, it would no longer be necessary. To this
type of behavior we must add the attitude we have towards death today: we run to hide it, to deny it,
especially intrauterine death, so that we can quickly say: nothing happened here. But nothing could be
further from the truth. As in childbirth, respecting the woman's time is fatal for the professionals'
schedules and the hospital infrastructure.
It is not surprising that in a time when everything has to be done so quickly, impatience occupies a
preeminent place in a process as hard as waiting for the outcome of the expulsion of a baby in
formation without life. Once it is known that the pregnancy has failed, the impatience comes from the
lack of knowledge of the physical labor of the abortion, of the mini-labor. Most of the time it is not
known exactly when the baby's heart stopped beating, the fatal outcome, but just when the
professional informs the woman, an incomprehensible rush invades him to act immediately, without
time for the couple to digest the news, without time to inform the various possibilities of approach.
The breast is usually curetted in a state of shock, stretched out on the verge of being put to sleep under
general anesthesia, most of the time, without having been able to react; full of fear, anguish, pain and
alone; without adequate accompaniment.
This haste deprives the woman of this fundamental accompaniment: neither her emotional needs nor
those of her partner are met, and sometimes there is even obstetric abuse. The baby's remains are
treated as an excised appendix, a surgical offal, a foul cyst to be thrown away.
An abortion, unlike childbirth, is not planned in advance unless the woman has undergone repeated
abortions, has a history of miscarriages and, just in case, respectful treatment is sought. This is why it
is so important for obstetrical professionals to be trained to care adequately in such circumstances for
bereaved parents who have suddenly found themselves in the worst of situations in their state of good
hope.
The advantages of natural abortion are rapid physical recovery, regaining confidence in one's own
body and its power and wisdom. It means being able to resume the search for the desired child the
moment the desire arises without having to wait for the uterine walls to recover from an artificial
curettage.
The approach to abortion with curettage takes into account a small part of the loss: the physical. The
problem is solved by immediate elimination. But abortion involves much more complexity and much
more to attend to; a range that encompasses the emotional, spiritual, psychic, social and cultural
spheres. The characteristics of these spheres feed back on each other, and it should be noted that they
are not resolved at the same time. It is obvious that a holistic approach to gestational loss is urgently
needed.

The expectant loss

The loss begins with bleeding. Today we can know that the baby's heart stopped weeks before the
blood began to flow. These weeks of waiting (which can be up to 8 weeks) are very hard for the
woman, impatient to end this emotionally painful stage; it takes a lot of support and a lot of wisdom to
undertake this path of waiting until the mini-pregnancy is triggered.
As in a full-term pregnancy, neither the day nor the hour when it will begin is known, but the woman
who has some knowledge of her body will notice certain signs that will indicate that the moment is
approaching. Maybe one day you will start to notice that your breasts are not as sensitive. Pregnancy
symptoms begin to disappear, as if it were involuted, although this is not always the case, and may
remain after the heartbeat has stopped. Low back pain may be another indication that something is
going on. The need to create a nest, to be at home, to clean, to tidy the cupboards, just as in the days
preceding childbirth, may be another indication. Some women report feeling pins and needles in the
belly.
Just as each woman experiences menstruation in a different way, so the physiological farewell to
childbirth can have as many stories as there are women on the planet. There will be similar, but never
the same; each one will have to go its own way.
One day it begins to stain pink. There may be expulsion of what would be the mucus plug, even if it is
only a few weeks old. The staining will increase, from pink to red, fresh blood, sometimes passing
through brown. The contractions will increase in intensity, time and strength. And the more intense the
contractions, the more debris in the form of clots will come out along with the blood: fragments of
different sizes that resemble the liver in texture and color.
We refer to pregnancies from the first to the twentieth week. The earlier in gestation the bleeding
occurs, the more it resembles a period, with abundant endometrial material, clots, the embryo,
amniotic fluid and blood, blood in abundance most of the time. If you want to recover the embryo, you
will have to be attentive and have a bedpan to pick it up from the clots.
Towards the end of the first 20 weeks, the loss will be more like a full-term delivery: with a small
baby, a placenta and a bag full of amniotic fluid. It would be interesting if women could go through
this experience accompanied by experienced people they trust: midwives, doulas... Sometimes it will
be enough with an attentive partner who is not afraid of blood and capable of accompanying them
through the pain, without intervening, rushing or giving instructions; the task is nothing more and
nothing less than to accompany, validating, empowering and without judging the woman. It is
important not to perform tactos to avoid infections or discomfort added to those already experienced
by the laboring woman. As in childbirth, there will be a dilation phase and an expulsion. You may feel
like being in the dark or in semi-darkness or going for a walk in the sun. There are no rules other than
those established by the woman. It is her body, her childbirth and her child.
Sometimes the process takes several days. Probably at night the body will start up with more
contractions, strong pain, heavier bleeding... all this for hours, leaving the rest of the day as a dull ache
that allows the woman to rest and recover from the physiological work. It is recommended to spend
these days in the peace and quiet of the home and to take walks to promote elimination but without
making great efforts.
What relieves pain in a physiological experience of loss is similar to what relieves pain in a full-term
birth: warm water, massages, dilatation ball...
If what was present was a tiny embryo, it may be detached before entering the phase of strong
contractions, a stage that will also come later, even if the embryo is no longer present. And the
ejection reflex can be felt: the force of the uterus expelling what is inside it, whether it is a live baby or
the remains of an arrested gestation.
Is it important to see a dead baby at a few weeks gestation? Generally, it is a human-shaped embryo
from much earlier than we imagine. The answer will depend on the person's curiosity, on what he/she
experiences on a daily basis, on whether or not he/she has already undergone more abortions. It cannot
be categorically stated that it is more or less traumatic to see it... or not to see it. It would take some
preparation as to what they expect to find and what it will be like, rather than saying whether or not it
will be traumatic. It would be appropriate to prepare the couple about what they are going to see or
may see, so we believe it is important that expectant management is experienced with the right
accompaniment. Blood, clots... can be perceived very differently having information, knowing what
can happen next. Knowing testimonies of expectant management helps the woman who chooses this
path to feel more confident in the process: what to expect, what bodily sensations... Then, it will be her
own experience that will count.
After expulsion of the remains, bleeding usually continues as in a quarantine. Sometimes it happens
that while still bleeding, the woman has the sensations of the next ovulation. Cycles stop. This has
been the case for millennia, and it is thanks to this that the different animal species have been
maintained on earth. It is a magic that those who go through this experience witness firsthand.
When does the period return? Approximately 30 to 40 days later. Sometimes this first period has just
washed away any small debris that may have remained in the uterus to prepare it for the next
fertilization.
Some women have reported that in a single afternoon they expelled everything, and that when the
ultrasound was performed it was seen that the work had already been done. Others required several
days (and nights). Others expelled the embryo and needed a little more time to expel the endometrial
tissues. Others, on the contrary, expelled a lot of endometrial content, but the embryo was slow to
detach. For some it was almost painless. For others it was extremely painful, much more than
childbirth (with full knowledge of the cause). A low percentage succeeded in expelling the embryo but
needed surgical help for the endometrial debris.
What they all say unanimously is a feeling of power, of strength during the whole process once the
labor pains begin and, above all, at the end. The word they usually use to express how they have felt is
powerful and they speak of euphoria. The natural oxytocin that courses through the body of a woman
in labor also invades the grieving mother. It is a potent antidepressant that physicians discourage in
favor of surgical treatment.
It is difficult to put it into words. The woman faces the loss of her baby, but from the knowledge and
wisdom that her body has given her. She is not only a woman who has lost her baby; she is a wise
woman who has overcome a great obstacle in the sea of life, emerging victorious and master of her
being. A woman who has regained her power. That is priceless.
We know of no studies that corroborate what the physiology of labor in the first weeks of gestation is
really like. Our story is extracted from our own experience and from the many testimonies collected in
the virtual community Overcoming Abortion, where so many mothers have shared their experience.
It is impressive to hear or read a woman who has lived her loss from the expectant handling of the
wreckage. From her stories there is a serenity, strength and security in her body, who knows how to do
her job well, which is not expressed by those who have undergone a curettage. Normally, the
termination of a pregnancy is experienced as a deep and personal failure in the depths of the female
being. The woman designed to beget life never expects that the result of her fecund womb will be
precisely death. This failure can be experienced as "I am badly made", "I am worthless" and even "my
own body has betrayed me". From the emotional sphere, it is extremely important that the woman who
feels such a degree of anger and rejection for her body that has failed her in the most important thing,
reconciles herself with the most precious thing she has and that will accompany her until her last
breath: her body.

The respected loss

It is time to demand respected losses at all gestational ages, not only at late gestational ages. At a time
when respected childbirth is a demand and a struggle that adds efforts exponentially at all levels,
respected childbirth cannot be an exception. A respected loss involves demanding and enforcing the
following rights:
a) To be informed about the different medical interventions that may be required if necessary, so
that she can choose freely when there are different alternatives according to scientific evidence.
b) To be treated with respect, and in an individual and personalized manner that guarantees privacy
throughout the care process, taking into consideration her cultural patterns and the place where the
woman is cared for.
c) To be considered as a healthy person, and the process of loss as physiological as long as there are
no significant alterations that indicate that it is determined to intervene in the process in some way, so
as to facilitate their participation as protagonist of the process of loss and decision making.
d) Delivering a stillborn baby respecting biological and psychological times, avoiding invasive
practices and medication that are not justified by the mother's state of health or that respond to the
mother's expressed desire to do it in a more medicalized way.
e) To be informed about the evolution of the loss process and, in general, to be made to participate
in the different actions of the professionals.
f) To be accompanied by a person of their choice and trust during the loss process, to be treated in
an empathetic manner, as well as to recognize their need for support throughout the process.
g) Have answers (or at least be sought) to the loss. Women need to know the causes of their losses
because it lessens their anguish, makes them feel better; if they know, they do not elaborate alternative
or moral explanations in the sense of deserving or not deserving that child.
h) Treat the human remains of abortion as what they are: the remains of a human being in the
making, not as unrecoverable surgical offal. Nor do they have the same consideration as an arm or a
leg, which may have a certificate of dysfunction and can be buried.
Without these basic rights, women will not be able to make informed decisions that fully affect their
health. We talk about taking responsibility for our decisions and making free choices, but this requires
correct prior information. If the information from the person who has knowledge on the subject by
studies, degree and/or profession is biased or if this information is not given to the patient directly, can
she be held responsible for her choice? The patient has not been given an answer to several
possibilities, but has been given only one possibility, and has accepted it without knowing that there
were others. Therefore, more than a choice, it would be an imposition. A woman's responsibility
towards her own sexual health in case of gestational loss is often severely affected by a lack of
information about the different approaches that can be taken.
The relationship between the health professional and the patient is not horizontal in our country today,
except in minority and isolated cases. It should be a sine qua non requirement to present all the
possibilities of action with updated information, as well as to recognize the limits of each professional
in order to, if necessary, refer the patient. It is necessary to leave time and space to clarify doubts, to
make decisions; so that they are directed and agreed upon. This question is especially important in
situations of gestational death because, at the neurological level, the parents are being informed in
conditions out of the ordinary, in shock, in a state of despair, sadness, uneasiness... which will vary
from one couple to another and from one woman to another, but which in all cases must be taken into
account. Every medical professional should know basic strategies on how to communicate bad news.
And midwifery professionals (doctors, midwives, nurses...) should be aware of how to deal with losses
because they are going to live with many of them throughout their working life. It will be far from
exceptional.
Very little consideration has been given to the woman's future fertile life; no one knows in advance
how many abortions she will face. Are nine lost women going to be approached with nine curettages
in the same woman? This has been the case so far in multiple losses on many occasions.
It is really surprising that, after a lifetime of gestational losses, the feelings and experiences of mothers
have been so little heard. Too many times they automatically pass into the category of invisible?
silenced? unable to think and decide?
The forgotten voices of women suffering loss cry out to be heard.
 CHAPTER 9
The new pregnancy

The bittersweet wait

The new pregnancy after the loss is full of fears, doubts and insecurities. It is a situation that will
be physically and emotionally draining, especially for the mother, but also for the father and close
family.
It's hard, the fear is paralyzing. Feeling that it could happen again is frightening. It is an
endurance test. A pregnancy after one or more losses is a psychic marathon. The innocence of
waiting has been lost forever. But we have good news: you don't live in this distress all the time.
There are truces. There are moments of peace, calm, illusion and renewed hope. Like a roller
coaster, the anguish returns. How often does the mother think that she must have gone crazy:
because of superstitions, extreme hypervigilance...!
A pregnancy after loss is like this: knowing and accepting it is much better, because the anguish
of thinking that this state negatively affects the new baby often assaults and increases the
suffering. Suffering because of the uncertainty of whether this baby is going to stay is not a cause
of gestational death; it is good to say it clearly. Repeat as many times as necessary. Living in the
same way something of what was done in the previous failed pregnancy does not kill the baby on
the way either: having the ultrasound in the same week, in the same place, on the same day of the
week, wearing the same clothes... are not determinant issues or triggers of misfortune. Although
these coincidences terrify many women, they are not a cause for loss. And we emphasize this
because everyone has felt this sense of lack of control in one way or another. It requires going
through it, through a new pregnancy, to try to end up with a live baby in your arms. It's that hard.
Can you imagine the professionals who accompany pregnancies after one or more losses?
These pregnancies are different, and must be treated and accompanied differently. Professionals
should be aware of the woman's possible emotional responses and provide specific care and
support during pregnancy, childbirth and puerperium according to the individual needs of each
family.
Susceptibility and fear are at the surface. A woman with a pregnancy after two losses, for
example, cannot go through the torture of having the sonographer go about his/her work making
funny faces, without saying anything or commenting: "let's see where the heartbeat is, I can't find
it...". It is too unbearable.
A pregnant woman after several losses spends a lot of extra energy in this new gestation; going
on with her daily life leaves her exhausted, anxiety attacks are not rare, despair at a small
symptom, the slightest spotting... Nothing will spare the mother in this new pregnancy from
living this way of the cross. And we can safely say that she will also have moments of joy at
having a new life in her womb: when she notices that everything is going well, when she is told...
Both emotions alternate throughout the pregnancy. It is a bittersweet wait.
Most women wait anxiously for the dreaded date to pass, and once the momentary joy has passed,
uncertainty returns and they discover that this will be the case until they hold the baby in their
arms. Innocence is lost forever and in all subsequent pregnancies. Some moms manage to find
strategies that help them, and make the second half of pregnancy, the one they did not experience
in the previous gestation, a little more bearable, a little more like innocent motherhood. There are
women who struggle to be well in this new pregnancy, not to live it in this constant emotional
anguish, but few succeed. It's good to know and enjoy the good times, which there are, in all
pregnancies after loss.
Many moms are tortured by how this roller coaster of feelings they are immersed in is going to
affect their baby on the way: like a fish chasing its tail, they think that this anxiety is going to
affect the new baby in gestation, and the anxiety grows, and the fear that it will affect grows, and
anxiety crises appear. It is important to note that if thoughts were so powerful, none of our babies
would have died because we wanted them with all our will and love; therefore, they are lost or
born for other reasons, too unknown yet.
More and more studies are dealing with the incidence of maternal stress in children: high levels of
anxiety cause biological changes in the receptor in charge of stress hormones in the baby, as it is
an individual more susceptible to anxiety. This research adds to the uneasiness of these mothers,
who cannot get rid of anxiety in many moments of pregnancy, as an intrinsic characteristic of the
importance of the physical and mental health of the mother during pregnancy is being
increasingly taken into account due to the impact that different studies show it may have.
According to Dr. Elbert, it is as if the fetus is receiving signals from its mother that it is about to
be born into a dangerous world. The adolescents of these mothers were more impulsive; they also
showed a lower threshold for stress and appear to be more susceptible to stress.
Sensitive parenting trumps prenatal stress. A mother's love can provide powerful protection
against the risks faced by her baby during gestation. Research shows that babies exposed during
gestation to elevated levels of stress hormones, which pose a risk, can escape this risk if their
mothers provide them with loving and sensitive care during their first years of life.
The doubt of bonding or not with the new baby for fear of a new loss is a very common dilemma
in these pregnancies. The answer is clear, but putting it into practice is complex. Better to link up,
or try to. If the baby lives, it will be great that there has been this attempt at bonding, and if it is
lost and there has been no bonding, the mother will feel guilty for not having had it. One woman
explained that she went shopping and fell in love with something for her baby, fear assaulted her
and she put it back in its place in the store. She also lost this baby, but regretted not having
bought that object, because it would be the only thing she would have of her baby, something
tangible to remind her of him in a sweet way, in a moment of illusion of that pregnancy.
There may be other babies as desirable as ours, but no more; therefore, let us not fear for the
times that we are afraid of losing him, because we mentally and permanently try to hold on to
him, to beg him and all forces and all beliefs to stay this time!
During the new pregnancy, the woman will feel much better if she has protection, introspection
and good accompaniment.
The feeling of lack of control invades the mother along with the desperate plea that this time the
baby will grow strong and develop healthily, because if another loss occurs she feels she will not
be able to bear it. Evidently if it is supported. Unfortunately, sometimes a woman lives through
more than one loss. The mother evidences that she can do nothing. Neither locking yourself in a
glass bell is a guarantee that everything will go well. No doctor can accurately predict that a
pregnancy will end with a healthy baby in the mother's arms.
If she is well, because she is too well without symptoms of pregnancy, and suffers for the life of
the baby. If it is bad, because it is bad and maybe it is a sign that something is not going well. The
woman feels that her thoughts are irrational, that she is getting out of balance, losing her
equilibrium, but she cannot do anything about it.
Some explain that it has helped them to accept these reactions, to flow with the fear, to admit that
there is nothing they can do to make it go well and that uncertainty will be present throughout the
pregnancy. It is useful for them to try to see these irrational thoughts for what they are, to identify
and observe them, accompanied by understanding. It is impossible to run away from fear because
they cannot avoid what they have experienced. Many mothers say that it is better to get all these
thoughts out: to elaborate, analyze and accept them, rather than trying to bury and silence them.
A common characteristic of these pregnancies is the impossibility of thinking about the future or
not wanting to talk about it. The gestation period is seen as a very long obstacle course, an
endurance test where you can't see the end, or where the happy ending is not at all clear. Someone
well-meaning may ask the mother when she is expecting the baby, and the thought comes to her
mind of who is thinking about the due date if she is looking forward to the next test and its
results. Good intentions and good wishes can also cause the mother to be told: "Don't worry, this
time it will go well". But it is nothing more than a wish and does not support anything that can
reassure the mother.
It should be noted that the dates of medical visits, ultrasounds, etc. are usually preceded by a few
days of growing anxiety, nightmares and anxiety. If the medical appointment went well, the calm
and respite last for a limited time, and then it's back to the beginning... If you feel that the date of
the next visit is far away, the anguish starts already for this reason.
A pregnant woman after loss is unable to make plans, with a calendar on the horizon of tests and
results, and in her head the idea that at any moment something can go wrong. Fear arises in
almost all cases, even before pregnancy, when the couple begins to consider trying again or when
the doctor announces the expected green light.
What can we do to control fear so that it does not drag us down: the first thing would be to
understand what fear is and how this emotion originates in our brain and what mechanisms it
employs. Only from there will it be possible to start working. Fear is part of us as human beings,
it is an emotion that serves us as a weapon for survival and, like anger, and although it has a bad
press, they are very necessary. Fear helps us to take precautions, to be attentive so as not to fall
into danger, it helps us to detect it. Anger helps us in the fight.
But sometimes fear can be like a small child, who screams so much that it invades us and does
not allow us to listen to him or to the rest of emotions, and, therefore, paralyzes us. What can we
do then: observe him, get to know him in order to detect his needs and meet them, to know
exactly what he wants to tell us. We often see fear as an enemy, and ignorance makes it greater,
but in reality it is our ally: we can use fear to grow and overcome our limitations. To do this, it is
key to understand how fear originates. For example, if we are sitting quietly at home and
suddenly hear a strange noise, the body will react in a linear way: the stimulus of the noise, which
a priori is not associated with any emotion, settles in our brain, and reaches our limbic system,
where it is compared with our experience, with the information we can use to understand it and
give it a meaning; if that noise cannot be identified, the body's response will be alert. Our senses
are heightened at the thought that it may pose a threat. Not only that, but the whole body is put on
alert and reacts by deciding between two possible courses of action: fight or flight. The heart will
pound the chest, we will breathe faster and deeper. The body and the brain undergo a myriad of
motor, sensory, endocrine and metabolic changes, among others, with the sole purpose of
directing all our capacity and energy to make the body as efficient as possible when facing or
fleeing if this noise that we are unable to identify is actually a threat. It is a reflex reaction that we
cannot control.
A similar reaction may occur in other situations that do not represent a physical threat as such. If,
for example, a person is waiting for someone who is very important to him/her, probably when
he/she sees that he/she is late, he/she will start to get nervous, uneasy because he/she fears to be
unnoticed, will look for his/her face among the people and will notice how all his/her senses are
sharpened. His heart will also beat when he thinks he recognizes her and, without realizing it, he
will breathe very fast. Similar changes will occur even if the stimulus is very different.
What happens is that our brain has a mechanism to respond to stimuli that uniquely alert us and
prepare or defend us for situations that have to do with our survival or matters that are especially
important to us. This reaction occurs in this unconscious way, but as we have already seen, other
situations also trigger this response in the absence of threat, although in the presence of worry or
concern. Our brain has to do a constant work to discern which things are threats and which are
not, trying to put weight and strength on what is real; otherwise, we would spend most of our life
in a state of exaggerated nervousness.
For such situations, the brain has a plan B. The stimulus that has created this instinctive reaction
also passes to another area of the brain where it is processed at a more conscious level: the
neocortex or cerebral cortex. There, our brain collates again the event that triggered the sequence.
It weighs everything and gives it a value, modifies and shapes the response. For example, if we
return to the case of the noise that alerted us, even if we are not clear about what type of noise it
is, we can look for other elements that help us to conclude that it is not a threat. We will then
consciously do the work of analyzing it and suddenly realize that it is really just a noise coming
from next door and is therefore nothing. We will send this information to the region of the brain
that is in charge of provoking the instinctive reaction and this, knowing that there is no danger,
will cause the body to return to calm. Our mind is permanently dialoguing with the different parts
that compose it, readjusting the information and giving each thing its specific value.
What about gestational losses? A series of apparently innocuous stimuli such as seeing a new
positive pregnancy test, reliving an ultrasound or other common aspects of a pregnancy, become
stimuli that trigger a reaction of fear and alertness because, after the loss, these events are
installed in our limbic system of the brain as traumatic events associated with the loss of the baby.
When our brain receives the stimulus related to pregnancy and it reaches the limbic system, our
brain identifies it as dangerous, as something that hurts us. And it generates the response of fear
and anguish, of alert, of uneasiness. Therefore, information must be taken to the next level. It is
necessary to undo that link that makes everything related to pregnancy generate fear and change it
for what it should be: a pleasant sensation linked to the new baby that is being gestated. One way
to achieve this is to make that rational part of the brain give arguments to the other parts of the
brain so that it believes that it is a different situation and that there is no reason to be afraid. We
can make a whole speech to convince ourselves. Sometimes it will work, but sometimes it will
not. What do we do then? If we fail to de-angst ourselves by talking to ourselves, we should know
that all is not lost. There are more options!
Unless our fear and anguish are very strong, in which case the most appropriate thing to do would
be to seek professional help to work on the trauma, one option that we can carry out is to
introduce in this context counter-stimuli that favor the tranquility of the brain and that overlap the
previous stimulus that is distressing us.
It is normal that the stimulus of something related to pregnancy triggers a reaction of fear and
anguish, because we have lived a very strong and traumatic experience that will mark us for life.
It is not something we can control, but we can prevent it from dragging us down, forcing our
brain to change the chip and focus on something else.
If the fear of gestational loss suddenly assaults us, we can do things to stop that thought and the
emotions it drags with it: pick up the phone and talk to someone who puts us in a good mood or
someone who talks to us about a thousand banalities and entertains our brain in the
conversation...; go into a store and ask a salesperson something; do some exercise suitable for
pregnancy; do some craft, something creative... It has been described that just drinking water
helps, because if the body has time to stop and drink water, that is already telling it that there is
not such a big threat. In addition, sometimes we reach the limit of dehydration and many nervous
states are caused simply by a lack of water in the body; drinking water and rehydrating ourselves
can be very therapeutic. We can fill our daily lives with things that help us not to think about the
loss, to distract our minds and to carry the pregnancy in a happier way.
It is important to learn to defocus, to take distance from situations and fill the hours with other
activities and different thoughts. There were those who overcame their fear by moving house,
filling their days with the illusion of moving to a bigger house... they no longer felt afraid of
losing it, because their time was occupied with paperwork, plans and new prospects for the future.
And if our mind needs to think and think, another strategy that can also help is the following: the
human mind has the particularity of living with the same intensity something that is real and
something that we imagine. That is why fear is so powerful in generating these emotions, because
we live a situation that has not yet happened (we do not know if it will happen) as if it were
already happening. But we can use this same mechanism to bring the body and our mind to live
the opposite situation. We can transform the thought of "what if this time this also happens...", to
"what if this time the opposite happens", and automatically hold on to the image of the baby that
right now, today, is alive, growing and receiving these good vibrations. The overwhelming
thought that triggers the clear image of the new baby is a very powerful counter-stimulus to
change our state of alertness to a state of calm.
We live by and for pregnancy, we will spend 9 months of obsession-compulsion that prevent us
from enjoying this beautiful stage. Many times, the mother stops doing activities that could
endanger the pregnancy. It is necessary to distinguish between activities that are hazardous or
risky and those that are not, and to focus on the latter. It can be difficult to find distractions to
grab a parent's attention at a time like this, but if you do, it helps to focus attention on the distress,
put it elsewhere, and enjoy both. Such a degree of obsession with pregnancy is a common state of
affairs, but we should not accept it without remedy. Psychotherapy can help a lot to reduce
anxiety states, recover calm and enjoy the moment, having processed and elaborated the previous
loss. There will always be some fear, it is inherent to life, but paralyzing fear is not a normal
human state.
We have to take into account, on the other hand, that fear has been elaborated throughout our life,
as well as the strategies to face it and the regulation of the physiological activity involved in each
emotion. The latest studies in neuroscience show that the brain structures involved are built by the
attachment established with the mother or primary caregiver. In addition to pregnancy, the way
we face and resolve our fears will also influence many other factors in the life of the woman, who
does not arrive at pregnancy and its loss as a blank canvas; the woman carries a backpack with
her that cannot be ignored, and that will influence in one way or another her fears and the
management of them.
Gary Vogel, psychotherapist and father of a child who died before her birth, says that to reduce
the impact of the loss and reduce this fear, it is important not to seek another pregnancy until
other stages after the loss have been overcome. It is important that the couple has had enough
emotional distance from their loss to be able to cope with another pregnancy and that they look
for another baby as something else in their lives, not something to help them find meaning in their
lives. Also, not to try to replace the dead baby, but to want another child and provide themselves
with a support system that can give them additional help in the next pregnancy. It would also be
appropriate for them to understand the risks involved in being pregnant again and the emotions
that may resurface.
Often this work is not done before the new pregnancy, and whatever is pending to be resolved
emotionally will come to light anyway. It is not something that can be skipped. In fact, when this
happens, the breast is often in the midst of pregnancy and following the stages of grief that
continue to occur after the new positive result.
Grief, anguish, fear... will always be there, but the mother has in this new pregnancy the
opportunity to focus on all the moments that the baby gives her.
Feeling how the new baby is forming and growing and how these moments will increase the
connection with him/her, providing spaces of great joy. Feeling that you can create life, that you
have possibilities and that you want to enjoy this baby. This present moment where the baby is
alive inside.
No one knows the future and what it holds.
Professional support: many couples who have suffered gestational losses get a device to listen to
their baby's heartbeat when they feel anguish or have doubts that the pregnancy is going well to
reassure themselves and not to go to the emergency room every time the alarm goes off for
whatever reason. Others buy it and use it for different reasons: because of a problem with the
present pregnancy or for the simple whim of listening to the heartbeat when they feel like it.
There is currently some controversy about the possible harm or not to the child. There is no
unanimity on its total innocuousness. It is known that at high intensities, ultrasounds cause
immediate effects after exposure, which could be thermal and mechanical; within the latter, we
find the generation of audible sounds, induction of cell movements in liquid media, electrical
changes in membranes, compression and expansion of bubbles within a liquid medium
(cavitation) and pressure changes.Within the latter, we find the generation of audible sounds,
induction of cell movements in liquid media, electrical changes in membranes, compression and
expansion movements of bubbles within a liquid medium (cavitation) and pressure changes.
Professionals should be aware of the potential harm that these radiations can cause and should try
to reduce exposure to the minimum necessary to extract the necessary medical information.
Instead of resorting to almost continuous listening to the fetal heartbeat to reduce distress,
adequate partner accompaniment could facilitate the management of the milieu and anxiety and
the recovery of confidence.
In such cases, professional accompaniment would basically consist of listening, validating and
responding to the needs of the couple in a state of good hope after a previous gestational loss;
accompanying with respect for their mixed feelings; taking into account the woman's obstetrical
history at each consultation; empowering the woman by verifying that everything is going well
and trusting in her capacity; taking the utmost care in carrying out ultrasounds and encouraging
the formulation of clear questions and answers; training in gestational/perinatal bereavement
through readings and/or seminars, or by participating in a support forum in case of this type of
loss, where the needs of the women are soon known.
Rituals for life
It may happen that the parents feel they must again say goodbye to the baby who died; in such a
case, a farewell ritual can be elaborated. We now present a series of proposals for those mothers
and family members who face the challenge of emotionally surviving a new pregnancy; rituals to
welcome the new baby in the womb.
The main problem a pregnant woman faces after having experienced a previous loss is that of
bonding with the new baby. On many occasions, rituals will be aimed at strengthening this bond,
not only between mother and baby, but also between the baby and siblings or other family
members.
There is a tendency to silence the new pregnancy: nothing is bought until the months before the
birth, or if it is bought it is not taken out... small gestures will be necessary to start weaving a
chain between mother and child.
The keepsake box: if it has the same name as the box that was made for the departed baby. If the
fear of not buying anything is based on "just in case I lose it", why not start creating a memory
box? It can be a box, a folder... All the things that constitute memories will be stored in it. When
the other baby passed away, you realized that you had few of her things; this time you can be
more aware of collecting her things: the pregnancy test, the pregnancy booklet with the visits, the
ultrasounds, the recipes... If your mother has such a good knitting hand, it's time to knit her a
blanket. Many couples remember with excitement that time they saw a cuddly stuffed animal that
they loved but didn't buy because it was too soon, and then the baby was gone and there was no
point in doing so. Take advantage of this opportunity: come into the store and buy a stuffed
animal or two. They are for your baby, for your child. Or a little suit. All of this can take months
to do. Keeping little things in your box with each passing month is a triumph. It is a memory box
for life. Perhaps we begin to die the day we are begotten. Why not create a memory box of that
baby and that pregnancy? Not everything has to be bought; you can make things with your own
hands, or if there are other children at home, have them draw pictures. Everyone should bond
with that new baby. Maybe grandpa has the skills of a carpenter and will make you a nice box to
store all these treasures....
Symbols: we will create this ritual with all those details that help to bond with the new baby: give
it a name, or at least have a list of possible names; take pictures of the baby's belly month by
month (better pictures from the side, where only the belly can be seen; at the end with all the
pictures one on top of the other it will be a very beautiful image of progression; write letters to
the baby on paper; open an email in his name and send him messages; create a blog in which to
make a chronicle of the pregnancy, in which friends and acquaintances will be able to collaborate
in their comments; knit blankets or sweaters, knitting and crocheting, knitting and
crocheting.Create a blog where friends and acquaintances can collaborate with their comments;
knit blankets or sweaters, embroider bibs with the name; celebrate a meal with the couple and/or
family and take a photo; create an album with photos and/or videos of the pregnancy; keep a
diary in which to write and paste photos, allowing the other children, if any, to participate...
The gestational date on which the previous pregnancy was stopped is often experienced with
anxiety in the new pregnancy; in such a case, this date can be marked with a ritual if it seems
appropriate. For this purpose, a diploma can be created for the baby and the mother certifying that
she successfully passed the dreaded date.
The underlying belief that a pregnant woman cannot attach her baby to her breast is in case I lose
it, so if I want it, I will suffer more. Precisely these rituals that we present are double-edged: if it
finally happens that this baby also dies, there will be many memories that will make the mourning
more bearable. Paradoxically, what seems to be more harmful in the long run (bonding) is, in the
end, more beneficial. And what seems to be the easiest thing (not bonding with the baby) is what,
in case of death, will turn the mourning into something difficult and arid.
Few things are sadder for a woman cradling her baby in her arms than being aware that she has
no physical memory of her pregnancy, a time of languor and joy that was only lived in fear and
anguish. Let's break with it. It is true that fear is inherent to human beings, but that does not mean
that we allow it to take control of our lives.
Mom: take back what is yours and enjoy one of the most beautiful and tender times of your life:
the gestation of your baby.
 CHAPTER 10
Delivery after loss

Fear
It is a human emotion that helps us to protect ourselves, to be alert. Being afraid is healthy. It is
logical to be afraid in certain situations.
Losing a baby we were expecting keeps us on our toes; it is logical not to want to go through the
same thing again. We need to further verify that everything is going well, that the pregnancy is on
course.
After a first baby whose heart stopped beating, subsequent pregnancies experience a state of
alertness that, although it is reduced after the dates of the previous loss, does not disappear until
the day the healthy baby arrives. There is also a greater difficulty in bonding with the baby
growing in the womb, in case the same thing happens. Thus, both subsequent pregnancies after
the loss and deliveries will be affected.
In addition to this fear, there are all the other fears related to childbirth. Factors influencing fear
and pain in childbirth: culture has led us to have a registered model of painful childbirth, from
which the woman has no possible escape. Although there have been cases of pleasant deliveries
throughout obstetric history, the myth of pain seems to be indelible. Expectations have a clear
effect. The mido influences the secretion of oxytocin, in turn influencing the muscular
movements of the uterus and, consequently, causing painful contractions. The lack of knowledge
of the physiology of childbirth on the part of the population in general and of the health workers
themselves in particular means that the accompaniment of childbirth (observation, monitoring,
use of invasive techniques) is an environment conducive to the secretion of adrenaline, thus
blocking the effect of the other neurohormones responsible for childbirth (oxytocin, dopamine,
etc.).The lack of knowledge of the physiology of childbirth on the part of the general population
and of the health care professionals themselves in particular, means that accompanying it
(observation, monitoring, use of invasive techniques) is a favorable environment for the secretion
of adrenaline, thus blocking the effect of the other neurohormones responsible for childbirth
(oxytocin, dopamine, etc.).
Studies and the experience of various professionals show that preparation for childbirth focused
on reducing fear and promoting a state of mental relaxation reduces pain. It would be important to
take these factors into account in preparation for childbirth after one or more losses.

PdP
Labor after one or more losses can be affected in many ways.
The birth of a new baby may be a reminder of the one that is gone, so the woman will be faced
with both feelings of faithfulness to the stillborn baby and fear of a new loss, increasing her
alertness levels. This fear can make contractions more painful. Trauma pain in the body, if not
previously released, can lead to more pain in labor. The contractions themselves may be a
reminder of the contractions of the body when the baby was lost.
The upcoming arrival of a live baby can give them a lot of strength and a very satisfying birth.
We know that uncertainty and fear block the effect of oxytocin, one of the hormones responsible
for childbirth and breastfeeding. Some studies have observed, for example, a relationship between
trauma and pain in childbirth.
For example, in a group of women with a history of childhood sexual abuse, almost all reported
pain in childbirth. Uncertainty and fear can affect the functioning of the uterine musculature and
the blood supply to the uterus, which can cause not only more pain but also a slower and harder
labor. All this, if not handled with care, can lead to more unnecessary interventions: oxytocin to
accelerate labor, fetal distress, use of instruments, cesarean section, mother-baby separation...
The emphasis should be on minimizing the sources of fear, building confidence in the mother,
empowering her and also using the same resources we have discussed for pregnancy to reduce
fear: defocusing, helping the mother not to think that her health or that of her baby may be
threatened in any way. This will be all the easier the more you have worked from this point of
view during gestation.
It would be very beneficial for the medical staff to have an empathetic attitude and not threaten
her with oxytocin or a cesarean section because of the slow progression of labor, as the woman
would feel more frustrated and distrustful of her ability to achieve this.
Although high-grade panic or fear of childbirth tends to be more prevalent in late gestational
losses or when those were related to childbirth, the fear of losing the baby again or having
something happen to the baby may still be anchored. Perhaps the fear is not processed at a
conscious level, but it will be installed in our brain, in our limbic system, so that all the stimuli
and circumstances of childbirth can bring it to light and trigger the reaction of fear and with it will
come the tension, the resistance to the progress of labor, to the contractions to follow...
Our uterus will have to fight against this resistance. The cervix will remain contracted, and each
contraction will have to be stronger, more intense and more frequent to soften and open it. This is
what generates the pain of childbirth. If we fail to break this vicious circle at some point, the pain
can grow like a spiral and become unbearable; and it can not only cause more pain, but delay,
block and hinder labor. Some mothers use this unbearable pain to give up in despondency, to
surrender to childbirth, to abandon themselves. In these cases, the Plan B that the body deploys in
the face of extreme pain can be of great help: the body will generate a cascade of endorphins that
lead the woman to an altered state of consciousness thanks to which she stops focusing on the
pain and childbirth flows again. But for this to happen, the birth must take place in the right
environment: empathy, respect, good accompaniment, warm temperature, safety... If this is not
possible in any way. Epidurals may be the key for the woman to get some respite and relax.
Although epidurals may facilitate relaxation and dilation in some women, it is not advisable to
resort to them without taking into account the disadvantages. In this case, the most important
thing for the woman's peace of mind and the proper progress of labor is the attention of health
professionals.
If the fear of childbirth is very intense at the end of pregnancy, some women, to avoid the
anxiety, will believe that a cesarean section is the safest option and will opt for a scheduled
cesarean section. Although the woman should always have the final decision on delivery, far from
cesarean section representing a safer option, it is the other way around. Cesarean section is a
delivery option that involves greater risks for both mother and baby. The decision to request a
cesarean section as a safer route has more to do with our view of the supremacy of technology
and medicalization over natural physiology, strongly rooted in our culture, but as the scientific
evidence shows, this belief is a mistake that holds no truth whatsoever. It would be desirable for
women considering a planned cesarean section to receive adequate care and information about
each intervention, and to obtain good informed consent about the risks of the interventions.
In general, women who have been able to experience expectant management are able to face the
delivery of a live baby with more internal tools, as they are more aware of their body's reactions
and regain confidence in it; after delivery, they feel full of endorphins, triumphant and strong.
They know that giving birth to a live baby is a prize they did not get with the loss, even if the size
changes. Expectant management of the loss is a good psychological preparation for future
deliveries. These women require a more careful, but not paternalistic, accompaniment, with more
patience and respect for time, without pressure, although this would really be the appropriate care
for any woman in labor, whether it is a live or dead baby, weighing 2 or 4kg.
In childbirth after one or more losses, several factors come together: the attitude of the mother
and her partner, the attitude of the professionals and her environment, and the physiological
consequences of the loss itself. It should not be forgotten that a birth after loss is not a risky birth,
but it is a special birth, although all births should be special. Under no circumstances should
women in labor be considered hysterical, neurotic or exaggerated. They have reason to feel this
way.
Is early gestational loss related to obstetric complications in subsequent pregnancies and
deliveries? A study conducted in the United Kingdom concluded that they do. Comparing women
who had previously had several miscarriages (averaging 9 weeks) with women who had had
successful pregnancies, the former had a higher risk of obstetric complications including:
preeclampsia, threatened miscarriage, preterm delivery, low birth weight, malpresentation,
postpartum hemorrhage, induced labor, instrumental delivery, and manual removal of the
placenta. However, it was found that these risks were no greater than in primiparous women, and
it was therefore concluded that women with gestational or perinatal losses behaved like
primiparous women in their subsequent pregnancies. This study dealt with the difficulty of
finding several investigations on a single previous abortion; the results do not determine the
origin of the risks, but they do point out that, for example, a premature delivery could be due to
the interventions performed in the previous abortions.
It is possible that, during childbirth, it is the father who is reactivated by the pain of the previous
loss. He (or she in the case of another woman) may also need attention. The couple will need
support and attention.
Once the baby is born, there is virtually no reason to separate the mother and baby. For any
mother it is essential to know that her baby is well, but when there have been previous losses,
even more so. The immediate establishment of breastfeeding is a very beneficial factor for both.
Sometimes, bonding difficulties with the new baby, if any, can be compensated by permanent
skin-to-skin contact with breastfeeding on demand.

CHAPTER 11
What did your baby teach you?

Despite the pain of loss, women are able to take something good out of this experience. After a
period of mourning, sometimes even at quite recent stages of the loss, they talk about what the
baby who left them has left them as a gift. There are technical terms to designate this reaction as
resilience, or in the case of trauma, post-traumatic growth.
Although going through this life experience is so hard for the mothers and none of them would
choose it consciously, there is a very important common point in all the testimonies: none of them
would change the time they spent with their babies in the womb, none of them would erase this
experience. They thank life for sending them this baby. Those who were not yet mothers, made
them mothers; those who already had children, learned fundamental aspects about themselves,
about life. They say they feel deeper, wiser, better people. They learn to love themselves, to take
care of themselves and to be more aware of themselves. It is a gift of long duration, and the
lessons they have taught are manifested not only at the onset of the loss, but throughout the
bereavement and throughout life.
What did your baby teach you? I don't just leave them with sadness. It also left them with a lot of
love, a growing love for the lost baby, for their partner, for the new people they met and
accompanied them... They value the discovery of a deeper, timeless, perennial love that goes
beyond a physical presence. Love in its purest form, some call it.
They learned to recognize what was true and important in their lives: the truth of many of their
social, family, work relationships... that were already that way but for many reasons they
overlooked it.
They learned that babies also die: without warning, without any symptoms, without even
suspecting it, and even if it happens so soon, in gestation time, their memory will last forever.
They all agree that the baby has taught them to value the present more, the importance of the here
and now. The past may be bitter, and the future is unknown. They have learned to value the little
things in life that are important to each of them. The loss has made them stronger: they have
realized how much more courageous and feisty they are than they ever thought they would be;
they can fall down again and again and get up and keep going. Seeing this courage reflected in
other women who have gone through the same thing (and seeing it for yourself) gives you a lot of
strength to get through the grief successfully, as well as to apply these new strengths to different
facets of your life. They learned to accept that life is not under our control, neither our own nor
that of others.
They consider banalities, superfluous aspects, issues that may be important to other innocent
mothers, such as the sex of the baby or having material things ready for its arrival or the fear of the
physical pain of childbirth.
They learned to value and know what helps them: silent and empathetic accompaniment instead of
empty words.
They learn to forgive each other, since they all felt guilty in one way or another for what
happened, and to value the time they lived together, the immense joy with which they received the
knowledge that they were pregnant and the excitement of being pregnant for some time, wonderful
sensations that they feel that reached the baby.
All the moms say they have never been the same; therefore, it was their babies that made them
different. This change does not mean anything to them so much a transformation into another
person, but rather the change of someone who has grown up, who has expanded their boundaries.
These creatures of fleeting life in our bosom did not just happen. It is part of the way to find out
about the gifts they brought us.
CHAPTER 12
Pedagogy of death

When we look at the formation of the individual, in the educational curriculum, we see that death
has no place. It is not talked about, it does not have a space. It is hidden in textbooks, in
classrooms, in our environment and in hospitals.
Gestational death is not discussed in the topics of sexuality and reproduction. On the other hand,
there is currently talk of assisted reproduction, that is to say, of problems that can occur in
fertilization and possible medical-scientific solutions, when it is precisely a major source of
gestational losses, of pregnancies that do not progress, of the loss of one of the twins, of embryos
that are rejected because the desired ones have already been implanted? Let us remember that the
success rate of these techniques is far from 100%.
Sex education and the couple's fertile life is focused on contraceptives and the possibility that a
woman can become pregnant around every corner, but people are not prepared for the difficulty of
conceiving when they finally want to.
When children grow up and reproduce, they do not find anything in books dedicated to
accompanying motherhood or in childbirth preparation classes that deal with this type of death. It
is like a bad omen from which the pregnant partner is protected. But it also leaves them illiterate
and helpless in the face of loss. One out of every 3 pregnancies is lost, it is not something so
exceptional, and no one has been prepared for it. Talking about gestational death in childbirth
preparation, in pregnancy books... does not kill intrautero babies. Talking about or discussing the
subject while pregnant, either. It is important to make this clear because it is a prejudice that exists
in pregnancy support settings.
It is important to prepare all people who are likely to have children for this possibility.
Our society has, with increasing intensity and urgency, the need to be trained on an emotional
level, a field that is very neglected in our culture. This emotional education should include the
subject of death and also specifically gestational death: what is a grieving process, its phases, the
feelings that may arise and the ways to cope with it. Focused on resilience, creativity, humor,
introspection... enriching emotional bonds, giving and receiving affection, empathy, altruism, self-
esteem... all with coherence and a sense of life. We would learn to cope with future gestational
losses and also any other traumatic situation.
It would be of great help, therefore, not only for fathers and mothers who will inevitably go
through it, but also for those who are lucky enough not to have to live through it, to know how to
better understand, accompany and help their friends, siblings or relatives who will experience a
loss. Who doesn't know someone who has lived through it? Who has not lost a sibling, a nephew,
a cousin, a neighbor... in gestation?

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